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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-BLCU3G
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
January 31, 2020		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.75
ARRIVAL
11:45 AM		DEPARTURE
03:30 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
7
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)
Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: Upon review of the facility's incident binder, it was noted that there was an incident report completed that was identified as reportable to Community Care Facilities Licensing (CCFL), it was not however submitted to CCFL.
Corrective Action(s): Please ensure that all reportable incidents are reported in the required manner, to CCFL.
Date to be Corrected: 31 Jan 2020.
Comments

Thank you to all the staff for their support with this inspection. Please feel free to contact your Licensing Officer with any questions you may have.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Jan 31, 2020
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.