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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBEL-CPCR85

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
Leila Thiessen

INSPECTION DATE
February 22, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6.75
ARRIVAL
09:45 AM
DEPARTURE
04:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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.

Care systems reviewed during inspections include the following: Licensing, Physical Facility, Staffing, Policies and Procedures, Care and Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Program, Records & Reporting. Staff files are not kept onsite, but are kept at the head office. Staff files will be reviewed at a later date.

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
LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: In a review of eight, one week menus and their corresponding audits, the following observations were made:
Not all snacks contained the minimum required two food groups. RCR s.62(2)(b)
The food servings sizes provided did not align with the food serving sizes documented in the audits.
Some food items were documented on the food audits in the incorrect food groups.
The menu and substitution records did not contain enough information to confirm that each time a substitution was made, it was from the same food group and had a similar nutritional value. RCR s.62(2)(d)
Corrective Action(s): Please ensure regular monitoring of the nutritional system to ensure the requirements are met.
Date to be Corrected: March 15, 2023


Comments

A copy of this report was provided electronically to the facility manager and no signature was collected.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required

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