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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-CKTSR8
FACILITY NAME
Waverly Seniors Village		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
LSEO-AG9ULX
FACILITY ADDRESS
8445 Young Rd		FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Sarah Riddell
INSPECTION DATE
November 02, 2022		ADDITIONAL INSP. DATE (multi-day)
November 03, 2022		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
01:00 PM		DEPARTURE
03:00 PM		ARRIVAL
10:00 AM		DEPARTURE
12:00 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up		# OBSERVED IN CARE
53
Introduction

A follow up inspection to Routine Inspection JSAT-CC7PBK , dated March 1 & 2, 2022, was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSP).

The following care systems were reviewed during this inspection:
- Licensing
- Physical Facility
- Policies and Procedures
- Care and Supervision
- Nutrition and food services

For resources for licensees, links to the Legislation (CCALA and RCR), and Residential Care Facility Inspection Reports posted online go to: www.fraserhealth.ca/residentialcare
Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
NUTRITION AND FOOD SERVICES: 37100 - RCR s.62(3) - The licensee must take all reasonable steps to ensure that the food served to persons in care follows the menu and, if unable to do so because of unforeseen circumstances, that the food provided to persons in care meets the nutritional requirements set out in subsection 62(2).
Observation: On review of the menu substitution record to ensure substitutions were not being made based on staff preference or convenience as contravened on the routine inspection, it was noted that the substitution list has not been used, and substitutions not recorded since August of 2022.
Corrective Action(s): Ensure menu substitutions are recoded, and ensure all reasonable steps are taken to ensure the food served to persons in care follows the menu, and substitutions are made from the same food group and have similar nutritional value.
Date to be Corrected: November 10, 2022
Comments

Discussed during the inspection:
-LO to send the site a bulletin regarding the legislative requirements RE: food and nutrition services
-Call bell audits and documentation of follow up by leadership
-Staffing updates
-Change of manger forms have been submitted for processing by LO

It is requested that a written response be submitted on or before November 10, 2022 describing how the above noted contraventions have been appropriately addressed and/or the plan for compliance with legislated requirements. The plan shall include a time line for any items that have not already been addressed. Please note that a follow-up inspection may be conducted to confirm compliance after the written response has been received by Licensing.

The inspection report was reviewed, discussed, and provided to the Licensee/Manager.

(Please note: due to infection control practices related to COVID-19 prevention, this inspection report was reviewed with the Manager, written off-site and forwarded to the Licensee. Therefore no signature was obtained.)
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Nov 10, 2022
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Click here for a description of each "Category" of violation displayed.