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PERSONAL RIGHTS ADULT COMMUNITY CARE FACILITIES (California)

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STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PERSONAL RIGHTS
ADULT COMMUNITY CARE FACILITIES
EXPLANATION: The California Code of Regulations, Title 22 requires that any person admitted to a facility must be
advised of his/her personal rights. Facilities are also required to post these rights in areas accessible to the public.
Consequently, this form is designed to meet both the needs of persons admitted to facilities and the facility owners who
are required to post these rights.
This form describes the personal rights to be afforded each person admitted to an adult community care facility. The form
also provides the complaint procedures for the client and representative/conservator. The facility staff or client
representative must communicate these rights in a manner appropriate for client’s ability.
This form is to be reviewed, completed and signed by each client and/or each representative/conservator upon admission
to the facility. The client and/or representative/conservator also has the right to receive a completed copy of the originally
signed form. The original signed copy shall be retained in the client’s file which is maintained by the facility.
TO: CLIENT OR AUTHORIZED REPRESENTATIVE
:
Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:
ACKNOWLEDGMENT: At the time of admission I have been personally advised of, and have received a copy of the
personal rights contained in the California Code of Regulations, Title 22.
(PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY)
(PRINT THE NAME OF THE CLIENT)
(SIGNATURE OF THE CLIENT) (DATE)
(SIGNATURE OF THE REPRESENTATIVE/CONSERVATOR)
(TITLE OF THE REPRESENTATIVE/CONSERVATOR) (DA
TE)
THE CLIENT AND/OR THE REPRESENTATIVE/CONSERVATOR HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE
LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS. THIS AGENCY IS:
NAME
ADDRESS
CITY ZIP CODE AREA CODE/TELEPHONE NUMBER
( )
LIC 613 (12/02) (Confidential)
PERSONAL RIGHTS
ADULT COMMUNITY CARE FACILITIES
Each client shall have rights, which include, but are not limited to the following:
(1) A right to be treated with dignity, to have privacy and to be given humane care.
(2) A right to have safe, healthful and comfortable accommodations, including furnishings and equipment to meet
your needs.
(3) A right to be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule,
coercion, threat, mental abuse, or other actions of a punitive nature. To be free from restraining devices,
neglect or excessive medication.
(4) A right to be informed by the licensee of provisions in the law regarding complaints, including the address and
telephone number of the licensing agency, and of information regarding confidentiality.
(5) A right to attend religious services and activities . Participation in religious services and other religious functions
shall be on a completely voluntary basis.
(6) A right to leave or depart the facility at any time, and to not be locked into any room or building, day or night.
This does not prohibit the development of house rules, such as the locking exterior doors or windows, for the
protection of the consumer.
(7) A right to visit a facility with a relative or authorized representative prior to admission.
(8) A right to have communications between the facility and your relatives or authorized representative answered
promptly and completely, including any changes to the needs and services plan or individual program plan.
(9) A right to be informed of the facility’s policy concerning family visits. This policy shall encourage regular family
involvement and provide ample opportunities for family participation in activities at the facility.
(10) A right to have visitors, including advocacy representatives, visit privately during waking hours provided the
visits do not infringe upon the rights of other consumers.
(11) A right to possess and control your own cash resources.
(12) A right to wear your own clothes, to possess and use your own personal items, including your own toilet
articles.
(13) A right to have access to individual storage space for your private use.
(14) A right to have access to telephones, to make and receive confidential calls, provided such calls do not infringe
on the rights of other clients and do not restrict availability of the telephone in emergencies.
(15) A right to promptly receive your unopened mail.
(16) A right to receive assistance in exercising your right to vote.
(17) A right to receive or reject medical care or health-related services, except for those whom legal authority has
been established.
(18) A right to move from a facility in accordance with the terms of the admission agreement.
Reference:
California Code of Regulations, Title 22, Division 6 - General Licensing Regulations, Section 80072; Section 81072, Social Rehabilitation
Facilities; Section 85072, Adult Residential Facilities; Section 87872, Residential Care Facilities for the Chronically Ill.
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PERSONAL RIGHTS ADULT COMMUNITY CARE FACILITIES (California)

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Completed 5 April 2021

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