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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-BA9VT9

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
March 14, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
01:45 PM
DEPARTURE
06:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
17

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)
If you have any questions regarding this report feel free to contact me at 604 918 7526 or
Valerie.dairon@fraserhealth.ca

Contraventions
Previous Inspection - Contraventions observed on FIR #KBOI-AVCR4D have been corrected.
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: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: The hot water temperature was 59 degrees Celsius. The manager reduced the temperature at inspection and will monitor it until it is under 49 degrees Celsius.
Corrective Action(s): Please provide a plan that will ensure that water accessible by the PIC's is not hotter than 49 degrees Celsius
Date to be Corrected: March 29, 2019

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: The following deficits were observed: -light bulbs were missing in 3 light fixtures,
- mirror in basement bathroom is becoming desilvered due to moisture from the sink splash
- back door outside staircase is rusty
- back of house fire escape wooden stairs have areas where the wood appears to have become soft and possibly rotten.
- 2nd floor "swamp" bedroom, the cupboard door is off its hinges and a 3"x 18" strip of Formica is missing from the sink cabinet
Corrective Action(s): Please provide a plan that will ensure monitoring of the facility for maintenance.
Date to be Corrected: Mar. 29, 2019

MEDICATION: 36140 - RCR s.70(4)(b) - A licensee may permit a person in care to self-administer medications if a plan for self-medication is (b) included in the care plan of the person in care.
Observation: A prescription container of pain cream was observed on the top of a dresser. There was no arrangement for self-administered medication, and the medication was not stored securely.
Corrective Action(s): Please ensure that the management of self-administered drugs is consistent with the facility "Self administered medications" policy.
Date to be Corrected: March 29, 2019


Comments

The menu was reviewed to find 2 food groups at some meals instead of 3 (RCR 62(2)(a)) , the cook stated that there were beverages in other food groups that do not appear on the menu. It was discussed that the menus were part of the nutrition monitoring process and it is helpful to see all of the food being offered. It was observed that, while other audit tools were used by the cook, there was no menu audit. Licensing will provide a copy of the menu audit tool to the facility cook.
Please provide a plan that will ensure that the menu reflects the food offered by the facility.

The inspection of records took place at the building next door to the facility. The description of persons living in this building may require consideration for licensing. This will be reviewed with the leadership in April/May. It was described to the manager and supervisor that as per licensing requirements, if there are 3 or more individuals at the same address, who receive 3 or more prescribed services, a license is required.

This facility has good access to prompt medical and dental coverage.

The facility is clean and well organized. I would like to thank the staff and residents 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
Mar 29, 2019

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