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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBOI-AF2U7W

FACILITY NAME
Last Door Recovery House
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
David Pavlus

INSPECTION DATE
October 24, 2016
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.25
ARRIVAL
11:30 AM
DEPARTURE
03:45 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care 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
· 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 operations.

Visit the CCFL website at www.fraserhealth.ca/your_environment/ccfl for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)

If you have any questions or concerns regarding this report, please contact me at 604-949-7730, or email, kara.bonkowski@fraserhealth.ca.

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: 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: Review of 4 staff files found that 3/4 did not include evidence of reference checks
Corrective Action(s): Ensure all staff files have evidence of references
Date to be Corrected: November 30, 2016

RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: Review of 4 client records and discussion with staff found that this consent is not currently obtained.
Corrective Action(s): Ensure that consent for emergency services is obtained for all PIC's
Date to be Corrected: December 31, 2016

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: Discussion with food services manager found that no menu audits have been completed. This is a repeat contravention from the 2015 routine inspection.
Corrective Action(s): Ensure that evidence of menu auditing is completed
Date to be Corrected: December 31, 2016


Comments

Thank you to the staff of the Last Door for their assistance with this inspection.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Nov 07, 2016

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