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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
FBES-CU2P9K
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 24, 2023		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.5
ARRIVAL
12:40 PM		DEPARTURE
01:55 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
· Policies & 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: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Medication safety and advisory committee policy requires staff to document effectiveness of PRN medication administered. PRN medication effectiveness were not recorded to 2 persons in care.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: August 8, 2023
Comments

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

Facility has maintenance plan in place for any repairs of the home Discussed with the staff to place a slip resistant material on the bottom of each bathtub and shower.

The findings were discussed with the facility leadership and 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 August 8, 2023.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Aug 08, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.