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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-B6Z2PC
FACILITY NAME
Topaz Place		SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
HSIT-6UBTCP
FACILITY ADDRESS
45438 Knight Rd		FACILITY PHONE
(604) 824-6164
CITY
Chilliwack		POSTAL CODE
V2R 5E6		MANAGER
Barbara Rusu
INSPECTION DATE
November 28, 2018		ADDITIONAL INSP. DATE (multi-day)
November 29, 2018		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6
ARRIVAL
11:00 AM		DEPARTURE
03:00 PM		ARRIVAL
01:45 PM		DEPARTURE
05:00 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
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 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 - Not Applicable
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: For the month of November, 2 prn medications were not documented on the back of the medication administration records as per the medication safety and advisory committee policies.
Corrective Action(s): Ensure all employees comply with the policies of the medication safety and advisory committee.
Date to be Corrected: December 28, 2018

RECORDS AND REPORTING: 39580 - RCR s.91(1)(a) - A licensee must ensure that all records referred to in this regulation (a) are current.
Observation: Review of three person in care records found that all three records had outdated personal profiles in two of the three binders accessible to staff.
Corrective Action(s): Ensure all records referred to in this regulation are current.
Date to be Corrected: December 28, 2018
Comments
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
Dec 28, 2018
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.