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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-CPS22Z
FACILITY NAME
The Waterford		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
0983055
FACILITY ADDRESS
1345 56th St		FACILITY PHONE
(604) 943-5954
CITY
Delta		POSTAL CODE
V4L 2P9		MANAGER
Tanya Snow
INSPECTION DATE
March 06, 2023		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5.5
ARRIVAL
10:00 AM		DEPARTURE
03:30 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

Routine Inspection Report

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). Evidence for this report was based on the licensing officer's observations, review of the facility records, and information provided by the facility staff at the time of inspection.

The following areas were reviewed:

- Licensing
- Physical Facility
- Staffing
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting

As part of this routine inspection a facility risk assessment tool is completed. The risk assessment includes contraventions identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.
Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: In review of the weight charts for January 2023, 4 persons in care were missing a recorded weight or a reason why the weight was not recorded.
Corrective Action(s): Please ensure each person in care is weighed at least once each month. If the person in care is not able to be weighed, please record the reason.
Date to be Corrected: March 24, 2023

RECORDS AND REPORTING: 39340 - RCR s.84(a) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (a) the type or nature of the restraint used.
Observation: In review of a person in care's health care records, it was determined that a restraint that has been approved is not recorded in the person in care's care plan.
Corrective Action(s): Please ensure that the following information is recorded in the care plan of the person in care, (a) the type or nature of the restraint used, and the plan for monitoring the person in care while the restraint is in use.
Date to be Corrected: March 24, 2023
Comments

This Licensing Officer would like to thank the Manager and Staff for their assistance in completing this routine inspection.

Please provide a response to Licensing by March 24, 2023 as to how the identified contraventions in this report will be addressed.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

(Please post this inspection in a prominent place in the care facility.)
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
Mar 24, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.