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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-C3ZUYE

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
June 11, 2021
ADDITIONAL INSP. DATE (multi-day)
June 15, 2021
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
9
ARRIVAL
11:30 AM
DEPARTURE
04:30 PM
ARRIVAL
10:40 AM
DEPARTURE
02:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting
·
As part of the 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 CCFL website at https://www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)

Contraventions
Previous Inspection -
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 (CORRECTED DURING INSPECTION): It was observed that water temperatures exceeded 49 degrees temperature.
Corrective Action(s): Ensure water temperatures accessible to persons in care do not exceed 49 degrees celcius. On day two of the inspection, the facility remedied the temperatures exceeding 49 degrees by ordering a new mixing valve to replace the broken item and lower facility water temperatures to mitigate risk.
Date to be Corrected:

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation (CORRECTED DURING INSPECTION): One tub room door was observed to be in a state of disrepair.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair. On day two of the inspection, facility implemented the first step to the door repair.
Date to be Corrected:

CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation (CORRECTED DURING INSPECTION): For one person in care, it was determined the Point of Care (POC) program that provides care staff with care required for each person, lacked a box to confirm monitoring for hourly checks at night was being completed.
Corrective Action(s): Ensure the care and supervision for persons in care is consistent with the terms and conditions of the person in care's care plan. On day two of the inspection, POC was updated to reflect appropriate monitoring of nightly checks being done.
Date to be Corrected:


Comments

The facility will be submitting a renovation health and safety plan for an outdoor patio space to CCFL for acceptance prior to commencement.

This inspection report was not signed by the facility manger and sent via email to the site to reduce the amount of time the licensing officers had to spend on site as per COVID-19 prevention measures.

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

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