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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

KBOI-AVCR4D

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 Jared Nilsson

INSPECTION DATE January 15, 2018	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3.45
ARRIVAL 01:00 PM	DEPARTURE 04:45 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED

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 www.fraserhealth.ca/residentialcare for: · Additional resources and · Links to the Legislation (CCALA & RCR)

Contraventions

Previous Inspection - Contraventions observed on FIR # have been corrected except for those noted on supplementary pages.

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: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair. Observation: On inspection the LO noted that a cabinet door in a PIC bedroom was not secured and falling off. Corrective Action(s): Ensure that all furniture for use by PIC's is maintained in a good state of repair Date to be Corrected: Feb 2, 2018 RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care. Observation: Review of the menu audit found that one week of the summer has been completed. The other 3 weeks of the spring summer menu and the 4 weeks of the fall/winter menu also need to be completed. Corrective Action(s): Ensure that results of food monitoring is complete for the menu Date to be Corrected: April 15, 2018

Comments

Last MSAC meeting was January 20th 2016, next one scheduled for first week of Feb. 2018. Thank you to the team at the Last Door for their assistance during the inspection.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Feb 08, 2018

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