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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-CZCNN2
FACILITY NAME
Willow Manor Care Centre		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
PWIN-6MEN2V
FACILITY ADDRESS
12275 224th St		FACILITY PHONE
(604) 466-8602
CITY
Maple Ridge		POSTAL CODE
V2X 6H5		MANAGER
Niki Tupper
INSPECTION DATE
January 09, 2024		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6.25
ARRIVAL
09:30 AM		DEPARTURE
03:30 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

This is a unscheduled routine inspection 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 the 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 and a copy is provided. The risk assessment includes non-compliance identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.

Visit the Community Care Facilities Licensing website at https://www.fraserhealth.ca/health-topics-a-to-z/licensed-care-facilities-and-assisted-living-providers#.YrT9QyfMI2w for:

- Additional resources, and
- Links to the legislation (C.C.A.L.A. and R.C.R.).
Contraventions
Previous Inspection - Not Applicable
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Two hot water temperatures taken at en-suite washroom sinks in the persons in care bedrooms measured at:

* 53.2 degrees Celsius.
*50.7 degrees Celsius.

During the inspection, the maintenance staff adjusted the hot water temperature and showed the documentation to log the hot water tempertatures. It is recommended a digitial thermometer be used to check the hot water temperature for the licenced care floor and document accordingly.
Corrective Action(s): Please ensure that water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Date to be Corrected: January 10, 2024.
Comments

Nutrition and Food Services:
- The Director of Care will review with the Dietitian to set-up audits for 2024 and capture when the audits need to be completed on the summary sheet as noted in the Audits and More Manual. As part of the response to this routine inspection report, please let your Licensing Officer know where things are at with this.

Thank you for the time taken by all staff who participated in this routine inspection. If there are any questions related to this routine inspection report, please contact your Licensing Officer.
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
Jan 10, 2024
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.