Fillable FACILITY EVALUATION REPORT (California)

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FACILITY EVALUATION REPORT (California)

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REFER TO
FACILITY EVALUATION REPORT
See other side for explanation of form.
FACILITY NAME DIRECTOR FACILITY NUMBER FACILITY TYPE
ADDRESS TELEPHONE
( )
CAPACITY CENSUS DATE
TYPE OF VISIT:
■
OFFICE
■
MANAGEMENT
■
PRELICENSING
■
ANNUAL
■
FOLLOW-UP
■
MET WITH
■
ANNOUNCED
■
UNANNOUNCED
TIME VISIT BEGAN
TIME COMPLETED
DEFICIENCY INFORMATION FOR THIS PAGE:
■
Type A
■
No Deficiency Cited
■
Type B
CIVIL PENALTY INFORMATION:
■
Penalty Assessed
■
Penalty Notice Given
■
Penalty Cleared
■
Not Applicable
COMMENTS/DEFICIENCIES PLAN OF CORRECTIONS (POCs)
POC
DUE DATE
Failure to correct the above cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a
civil penalty assessment.
LICENSING EVALUATOR SIGNATURE TELEPHONE
( )
DATE
I understand my licensing appeal rights as
explained on the back of this form.
NAME OF SUPERVISOR TELEPHONE
( )
FACILITY REPRESENTATIVE SIGNATURE DATE
LIC 809 (12/15)
Page ______ of ______ pages
AGENCY COPY
FACILITY EVALUATION REPORT – California law requires a public report of each licensing visit. This report is a
licensing record for the facility and the licensing agency. This report is available for public review; therefore, care is
taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance and contents
of these reports may be directed to the evaluator or office whose address and telephone number are listed on the front.
DEFICIENCIES – Deficiencies are noncompliances with licensing law or regulations. Licensees must be notified in
writing of all licensing deficiencies. Deficiencies may be identified on the left side of this form with a code reference to
identify the section of statute or Title 22, California Code of Regulations, upon which the deficiency is based. There are
two types of deficiencies:
• Type A deficiencies are violations of the regulations and/or Health and Safety Code that, if not corrected, have a
direct and immediate risk to the health, safety or personal rights of clients in care.
• Type B deficiencies are violations of the regulations and/or the Health and Safety Code, that, without correction,
could become a risk to the health, safety or personal rights of clients, a recordkeeping violation that would impact
the care of clients and/or protection of their resources, or a violation that would impact those services required to
meet the clients’ needs.
PLANS OF CORRECTION (POC) – Licensing laws require the licensing agency to establish the time for correction. In
order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of
clients/residents involved and the availability of equipment and personnel. Applicants/licensees are requested to provide
a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan,
the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The licensee who
encounters problems beyond his/her control in completing the corrections within the specified time frame may request
and may be granted an extension of the correction due date by the licensing agency.
CORRECTION NOTIFICATION – The applicant/licensee is responsible for completing all corrections and promptly
notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any letters sent
to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date,
person contacted, and information given.
CIVIL PENALTIES – When a deficiency exists, licensing agencies are required by law and regulation to issue a Penalty
Notice to all facilities holding a community care facility license except family day care, foster family homes, or any
governmental entity.
PENALTY NOTICE GIVEN – The statement concerning civil penalties serves as a penalty notice on this Licensing
Report and failure to correct cited licensing deficiencies will result in civil penalties. Licensees are required to pay civil
penalties if deficiencies are not corrected within the established plan of correction date.
APPEAL RIGHTS – The applicant/licensee has a right without prejudice to discuss any disagreement in this report with
the licensing agency concerning the proper application of licensing laws and regulations. When civil penalties are
involved, the licensee may request a formal review by the licensing agency to amend, extend the due date, or to dismiss
the penalty. Requests for civil penalty review shall be made in writing within 15 business days of receipt of a deficiency
notification (Penalty Notice) for Penalty Assessment.
AGENCY REVIEW – The licensing agency review of an appeal may be conducted based upon information provided in
writing by the licensee. The applicant/licensee may request an office interview to provide additional information. The
applicant/licensee will be notified promptly in writing of the results of the agency review.
LIC 809 (12/15)
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REFER TO
FACILITY EVALUATION REPORT
See other side for explanation of form.
FACILITY NAME DIRECTOR FACILITY NUMBER FACILITY TYPE
ADDRESS TELEPHONE
( )
CAPACITY CENSUS DATE
TYPE OF VISIT:
■
OFFICE
■
MANAGEMENT
■
PRELICENSING
■
ANNUAL
■
FOLLOW-UP
■
MET WITH
■
ANNOUNCED
■
UNANNOUNCED
TIME VISIT BEGAN
TIME COMPLETED
DEFICIENCY INFORMATION FOR THIS PAGE:
■
Type A
■
No Deficiency Cited
■
Type B
CIVIL PENALTY INFORMATION:
■
Penalty Assessed
■
Penalty Notice Given
■
Penalty Cleared
■
Not Applicable
COMMENTS/DEFICIENCIES PLAN OF CORRECTIONS (POCs)
POC
DUE DATE
Failure to correct the above cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a
civil penalty assessment.
LICENSING EVALUATOR SIGNATURE TELEPHONE
( )
DATE
I understand my licensing appeal rights as
explained on the back of this form.
NAME OF SUPERVISOR TELEPHONE
( )
FACILITY REPRESENTATIVE SIGNATURE DATE
LIC 809 (12/15)
Page ______ of ______ pages
FACILITY COPY
FACILITY EVALUATION REPORT – California law requires a public report of each licensing visit. This report is a
licensing record for the facility and the licensing agency. This report is available for public review; therefore, care is
taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance and contents
of these reports may be directed to the evaluator or office whose address and telephone number are listed on the front.
DEFICIENCIES – Deficiencies are noncompliances with licensing law or regulations. Licensees must be notified in
writing of all licensing deficiencies. Deficiencies may be identified on the left side of this form with a code reference to
identify the section of statute or Title 22, California Code of Regulations, upon which the deficiency is based. There are
two types of deficiencies:
• Type A deficiencies are violations of the regulations and/or Health and Safety Code that, if not corrected, have a
direct and immediate risk to the health, safety or personal rights of clients in care.
• Type B deficiencies are violations of the regulations and/or the Health and Safety Code, that, without correction,
could become a risk to the health, safety or personal rights of clients, a recordkeeping violation that would impact
the care of clients and/or protection of their resources, or a violation that would impact those services required to
meet the clients’ needs.
PLANS OF CORRECTION (POC) – Licensing laws require the licensing agency to establish the time for correction. In
order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of
clients/residents involved and the availability of equipment and personnel. Applicants/licensees are requested to provide
a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan,
the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The licensee who
encounters problems beyond his/her control in completing the corrections within the specified time frame may request
and may be granted an extension of the correction due date by the licensing agency.
CORRECTION NOTIFICATION – The applicant/licensee is responsible for completing all corrections and promptly
notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any letters sent
to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date,
person contacted, and information given.
CIVIL PENALTIES – When a deficiency exists, licensing agencies are required by law and regulation to issue a Penalty
Notice to all facilities holding a community care facility license except family day care, foster family homes, or any
governmental entity.
PENALTY NOTICE GIVEN – The statement concerning civil penalties serves as a penalty notice on this Licensing
Report and failure to correct cited licensing deficiencies will result in civil penalties. Licensees are required to pay civil
penalties if deficiencies are not corrected within the established plan of correction date.
APPEAL RIGHTS – The applicant/licensee has a right without prejudice to discuss any disagreement in this report with
the licensing agency concerning the proper application of licensing laws and regulations. When civil penalties are
involved, the licensee may request a formal review by the licensing agency to amend, extend the due date, or to dismiss
the penalty. Requests for civil penalty review shall be made in writing within 15 business days of receipt of a deficiency
notification (Penalty Notice) for Penalty Assessment.
AGENCY REVIEW – The licensing agency review of an appeal may be conducted based upon information provided in
writing by the licensee. The applicant/licensee may request an office interview to provide additional information. The
applicant/licensee will be notified promptly in writing of the results of the agency review.
LIC 809 (12/15)
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Completed 17 January 2021

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