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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
FBES-CG5SK9

FACILITY NAME
Westminster House
SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
2582023
FACILITY ADDRESS
228 7th St
FACILITY PHONE
(604) 524-5633
CITY
New Westminster
POSTAL CODE
V3M 3K3
MANAGER
Susan Hogarth

INSPECTION DATE
July 08, 2022
ADDITIONAL INSP. DATE (multi-day)
July 12, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
10:45 AM
DEPARTURE
12:00 PM
ARRIVAL
11:00 AM
DEPARTURE
12:15 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). 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#.W2NubJioupo 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: 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: A stairway wall had a punch hole measures 5cm x 4cm. Another stairway wall has two openings on both sides approximately measures 10cm x 8 cm.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: August 31, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation (CORRECTED DURING INSPECTION): A telephone wire across the stair was not anchored properly which is a potential tripping hazard.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: July 12, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: A fire extinguisher in the basement has no service date indicated.
Corrective Action(s): Please ensure that equipment are inspected and maintained on a regular basis.
Date to be Corrected:

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: One of 4 persons in care has no evidence of compliance to the Province's immunization and tuberculosis programs.
Corrective Action(s): A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis programs.
Date to be Corrected: July 26, 2022

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: A box of taco shells past its best before date was stored in the basement food storage room.
Corrective Action(s): Please ensure that all food is safely stored.
Date to be Corrected: July 26, 2022


Comments

Thank you to all the staff for their assistance and cooperation with the completion of this routine inspection.
The report was written off-site and therefore not signed. The findings were discussed with the facility leadership while the licensing officer was on 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 July 26, 2022.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Jul 26, 2022

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