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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-BLZVCK

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
February 21, 2020
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
01:00 PM
DEPARTURE
04:00 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 and Assisted Living Act (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). 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 · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · 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 CCFL website at :http://www.gov.bc.ca/residentialcarefacility
· Additional resources, and
· Links to the Legislation (CCALA and RCR)

Contraventions
Previous Inspection - Contraventions observed on FIR #VDAN-BA9VT9 have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
STAFFING: 32083 - RCR s.37(3)(c) - Despite this section, a licensee may employ a person as a volunteer who does not provide care to persons or supervise persons if the licensee or manager has first met with the person and obtained all of the following: (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Review of 2 volunteer files determined that 2/2 did not have evidence of compliance with the Province's immunization and tuberculosis control programs.
Corrective Action(s): Ensure that all volunteers have complied with the Province's immunization and tuberculosis control programs.
Date to be Corrected: 21 Feb, 2020

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Upon review of 3 person in care records, it was determined that 2/3 were missing evidence of compliance with the tuberculosis control program. Discussion with the facility manager finds that they are aware of the legislative requirement but have encountered challenges when trying to access TB testing services in the community. This LO suggested connecting with the local Public health Unit.
Corrective Action(s): Ensure that all PICs have complied with the TB program within 30 days of admission as per the most recent TB Testing Guideline.
Date to be Corrected: 28 Feb 2020

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: Upon review of the nutrition monitoring systems it was determined that there was not a menu checklist in place to document that the menu in use is meeting the dietary requirements of the Canada Food guide.
Corrective Action(s): Ensure that a menu checklist is completed for each menu.
Date to be Corrected: 21 Mar 2020


Comments

Thank you to the staff for your assistance with this inspection. Please feel free to contact your Licensing Officer with any questions or concerns you may have.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Feb 28, 2020

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