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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-ATMPRN
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 27, 2017		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
01:00 PM		DEPARTURE
04:30 PM		ARRIVAL
DEPARTURE
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 www.fraserhealth.ca/residentialcare 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: Review of medication administration records for three persons in care, 3 signatures were missed for administration.
Corrective Action(s): Ensure staff comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: January 6, 2017

CARE AND/OR SUPERVISION: 34640 - RCR s.81(3)(c)(i) - A care plan must include all of the following: (c) a nutrition plan that (i) assesses a person in care's nutrition status.
Observation: Nutrition forms were not not completed for all three of the three persons in care audited. Last completed forms were dated August 2016.
Corrective Action(s): Ensure nutritional assessment is completed for all persons in care.
Date to be Corrected: January 6, 2017
Comments

The medication safety and advisory committee and the staffing checklist to meet legislative requirements were reviewed off site as there was a delay in locating the documentation.

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
Jan 06, 2017
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.