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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-BE7VP7

FACILITY NAME
White Rock Seniors Village
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
LSEO-AG9VDP
FACILITY ADDRESS
15628 Buena Vista Ave
FACILITY PHONE
(604) 541-4663
CITY
White Rock
POSTAL CODE
V4B 1Z4
MANAGER
Denise Ewert

INSPECTION DATE
July 18, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7.75
ARRIVAL
09:45 AM
DEPARTURE
05:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
70

Introduction

Introduction
An unscheduled routine inspection was conducted in the presence of the General Manager/Manager 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 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/residential-care-licensing#.W2CWtTpKipp for:

- Additional resources, and
- Links to the legislation (CCALA and RCR).

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
STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: A random review of four staff files indicated for a staff member there was no criminal record check on file.
Corrective Action(s): Please ensure all staff where applicable have criminal record check on their file.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

STAFFING: 32020 - RCR s.37(1)(b) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (b) character references in respect of the person.
Observation: A random review of four staff files indicated for two staff there were not references noted in their files.
Corrective Action(s): Please ensure all staff where applicable have references noted on their files.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

STAFFING: 32030 - RCR s.37(1)(c) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (c) a record of the person's work history.
Observation: A random review of four staff files indicated two staff did not have work history noted in their files.
Corrective Action(s): Please ensure work history is noted in the staff files where required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: A random review of four staff files indicated for two staff there were no immunizations and/or Tuberculosis status in their files.
Corrective Action(s): Please ensure all staff where applicable have immunizations and Tuberculosis status noted in their files.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: A random review of the medication system including a medication cart and medication administration records indicated a few staff initials were noted on the front of the medication administration records. Specifics were provided at the time of the inspection.

Also an example was given whereby some staff initials are not noted for certain days and the care staff clarified the medication is not being used at this time, however there is no indication that is the case on the medication administration records. Specifics were provided during the time of the inspection.
Corrective Action(s): Please ensure all staff comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: Snacks are not documented and will be put on the menu as discussed with the General Manager.
Corrective Action(s): Please ensure as per section 62(2)(b) of the Residential Care Regulation this requirement is met.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: A review of the substitution list indicated on May 26, 2019 that icecream was substituted with short cake. The General Manager will look into this to ensure staff are substituting from the same food group and have a similiar nutritional value.
Corrective Action(s): Please ensure all staff are substituting from the same food group and have a similiar nutritional value.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.


Comments

Records and Reporting:

- A few documents did not have signatures noted however overall the documentation appeared to be thorough. Specifics were provided at the time of the inspection. Please let the writer know how you plan to address this.

- The General Manager will follow-up with the Director of Care and forward to the writer any ongoing tray service approved by the Doctor and assessed every 30 days thereafter by the Dietitian.

Thank you for the time taken to complete 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 LicensingFollow-up Inspection Required
Due Date
Aug 01, 2019
Approximate Follow Up Date
21 Aug, 2019

Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.