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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
FBES-CX5SXS

FACILITY NAME
Last Door Recovery Centre
SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
2582040
FACILITY ADDRESS
323 8th St
FACILITY PHONE
(604) 525-9771
CITY
New Westminster
POSTAL CODE
V3M 3R3
MANAGER
Jason Maier

INSPECTION DATE
October 31, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.75
ARRIVAL
01:15 PM
DEPARTURE
02:30 PM
ARRIVAL
DEPARTURE
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). 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/health-topics-a-to-z/residential-care-licensing

Residential Care Regulation
Community Care and Assisted Living Act

Contraventions
Previous Inspection -
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 (CORRECTED DURING INSPECTION): One of 5 staff files did not have a valid criminal record check on file. CRC renewal was processed October 31, 2023 for the staff.
Corrective Action(s): It is a requirement that a licensee must renew the criminal record check for an existing employee every 5 years. Employees without criminal record check must not work with persons in care.
Date to be Corrected: November 14, 2023

STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: The Licensee’s policy and procedure required that staff’s performance review are completed annually. One of 5 staff had their last performance review completed in January 2022.
Corrective Action(s): Staff performance review must be completed according to the licensee's policies and procedures.
Date to be Corrected: November 14, 2023


Comments

Thank you to all the staff for their assistance in the completion of this focused routine inspection.

A discussion with the facility leadership about the findings as well as to continue the process of labelling prepared food in the fridge and to ensure that the water temperature is not heated more than 49 degrees celsius.
The report was written and signed at the site. The copy of the report and risk assessment were provided via email.

Please submit a written response to this routine inspection to Licensing by November 14, 2023.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Nov 14, 2023

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