Let’s face it- inspection time is extremely stressful! No matter how much you have prepared or how long you have been in the “industry” when an inspector shows up to your community it can be a nerve-wracking experience. In the state of California the CCLD can show up anytime they see fit to conduct an inspection of every nook and cranny of the facility. Be prepared, be cordial and be open with inspectors and you will certainly have a much better experience.
87756 EVALUATION VISIT
- Every residential care facility for the elderly shall be evaluated as specified in Health and Safety Code section 1569.33.
Health and Safety Code section 1569.33 provides in part:
“(a) Every licensed residential care facility for the elderly shall be subject to unannounced visits by the department. The department shall visit these facilities as often as necessary to ensure the quality of care provided.
(b) The department shall conduct an annual unannounced visit of a facility under any of the following circumstances:
(1) When a license is on probation.
(2) When the terms of agreement in a facility compliance plan require an annual evaluation.
(3) When an accusation against a licensee is pending.
(4) When a facility requires an annual visit as a condition of receiving federal financial participation.
(5) In order to verify that a person who has been ordered out of the facility for the elderly by the department is no longer at the facility.
(c) The department shall conduct annual unannounced visits to no less than 20 percent of facilities not subject to an evaluation under subdivision (b)… (d) Under no circumstance shall the department visit a residential care facility for the elderly less often than once every five years.”
(b) Any number of other visits may be made to a facility for various purposes as determined to be necessary by the licensing agency to determine compliance with applicable laws and regulations.
(c) When a routine visit, evaluation or investigation of a complaint is conducted and the evaluator determines that a deficiency exists, the evaluator shall issue a notice of deficiency, unless the deficiency is minor and corrected during the visit.
(d) Prior to completion of a visit, evaluation or investigation, the evaluator shall meet with the licensee, administrator, operator, or other person in charge of the facility to discuss any deficiencies noted. At the meeting, a plan for correcting each deficiency shall be developed and included in the notice of deficiency. Prior to completion of the visit, the evaluator shall serve the notice of deficiency on the licensee by either:
(1) Personal delivery to the licensee, or
(2) If the licensee is not at the facility site, leaving the notice with the person in charge of the facility and also mailing a copy to the licensee.
(3) If the licensee or the person in charge of the facility refuses to accept the notice, a notation of the refusal shall be written on the notice and a copy left at the facility.
(A) Under such circumstances, a copy of the notice shall also be mailed to the licensee.
(e) The notice of deficiency shall be in writing and shall include:
(1) A reference to the statute or regulation upon which the deficiency is premised.
(2) A factual description of the nature of the deficiency fully stating the manner in which the licensee failed to comply with specified statute or regulation, and the particular place or area of the facility in which it occurred.
(3) The plan developed, as specified in (d) above, for correcting each deficiency.
(4) A date by which each deficiency shall be corrected.
(A) In prescribing the date for correcting a deficiency, the evaluator shall consider the following factors:
- The seriousness of the deficiency.
- The number of residents affected.
- The availability of equipment or personnel necessary to correct the deficiency.
- The estimated time necessary for delivery and any installation of necessary equipment.
(B) The evaluator shall require correction of the deficiency within 24 hours and shall specify on the notice the date by which the correction must be made whenever penalties are assessed pursuant to Sections 87761(c), (d) and (e).
(C) The date for correcting a deficiency shall not be more than 30 calendar days following service of the notice of deficiency, unless the evaluator determines that the deficiency cannot be completely corrected in 30 calendar days. If the date for correcting the deficiency is more than 30 days following service of the notice of deficiency the notice shall specify action which must be taken within 30 calendar days to begin correction.
(5) The amount of penalty which shall be assessed and the date the penalty shall begin if the deficiency is not corrected by the specific due date.
(6) The address and telephone number of the licensing office responsible for reviewing notices of deficiencies for the area in which the facility is located.
Pro Tip:
- Work with the surveyor and their teams needs
- Be professional and try to develop a rapport with the surveyor
- Be honest
- Use their feedback to make needed changes to your facility
Remember, they are not here to hurt your facility. They are there to make sure we as operators are doing all we can do to ensure residents are being cared for in the best way possible.