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LIC809. Facility Evaluation Report

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STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESFACILITY Evaluation REPORTREFER TOSee other side for explanation of NAMELICENSING EVALUATOR SIGNATURETELEPHONE( )DATEFACILITY REPRESENTATIVE SIGNATUREDATEI understand my licensing appeal rights asexplained on the back of this ( )NAME OF SUPERVISORADDRESSCOMMENTS/DEFICIENCIESPL AN OF CORRECTIONS (POCs)POCDUE DATETYPE OF VISIT: OFFICE MANAGEMENT PRELICENSING ANNUAL FOLLOW-UPDEFICIENCY INFORMATION FOR THIS PAGE: Type A No Deficiency Cited Type BCIVIL PENALTY INFORMATION: Penalty Assessed Penalty Notice Given Penalty Cleared Not Applicable MET WITH ANNOUNCED UNANNOUNCEDTELEPHONE()CAPACITYCENSUSDATE TIME VISIT BEGANTIME COMPLETEDDIRECTORFACILITY NUMBERFACILITY TYPEFailure to correct the above cited deficiency(ies), on or before the plan of Correction (POC) due date, may result in acivil penalty 809 (12/15)AGENCY COPYPage ______ of ______ pagesFACILITY Evaluation Report California law requires a public Report of each licensing visit.

COMMENTS/DEFICIENCIES PLAN OF CORRECTIONS (POCs) POC DUE DATE. ... 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 ...

  Report, Evaluation, Safety, Plan, Facility, Facility evaluation report

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