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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
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FACILITY NAME
Vanmar Place
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
ROLE-9C9SWH
FACILITY ADDRESS
6699 Vanmar St
FACILITY PHONE
(604) 792-7726
CITY
Chilliwack
POSTAL CODE
V2R 2M1
MANAGER
Kami Edwards

INSPECTION DATE
September 17, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
10:45 AM
DEPARTURE
01:15 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. Staffing was not assessed during this inspection as files are kept at facility organization Head Office and 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 - Contraventions observed on FIR # have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
MEDICATION: 36040 - RCR s.68(2)(a) - A licensee must appoint a supervising pharmacist to (a) serve on the medication safety and advisory committee.
Observation: The most recent Medication Safety and Advisory Committee meeting minutes provided were dated April 2019.
Corrective Action(s): Ensure the Medication Safety and Advisory Committee meets regularly, including the supervising pharmacist.
Date to be Corrected: October 11, 2021

MEDICATION: 36050 - RCR s.68(2)(b) - A licensee must appoint a supervising pharmacist to (b) inspect the areas of the facility where medications will be stored.
Observation: The most recent Medication Room inspection documentation provided by facility was dated April 2019.
Corrective Action(s): Ensure the supervising pharmacist completes medication room inspections on a regular basis.
Date to be Corrected: October 11, 2021

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: Menu provided showed evidence of six instances of only one food group offered per snack.
Corrective Action(s): Please ensure snacks in the meal plan each contain at least two food groups as described in Canada’s Food Guide.
Date to be Corrected: October 1, 2021


Comments

LO had discussion with facility regarding a new pharmacy they have begun to work with, starting on September 1, 2021 and the new Medication Administration practices. For their reference and/or use, facility management was sent copies of Health Professions Act, Schedule F, Part 3.
Please submit a written response by October 11, 2021 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.
This inspection report was not signed by management as it was reviewed with management over the telephone and sent via email to the site

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
Oct 11, 2021

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