(X2) MULTIPLE CONSTRUCTION & BUILDING: B. WING. STREETADDRESS, Cr-fl, STATE, ZIP CODE 4250 AUBURN BLVD SACRAMENTO, CA 95841
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1 & BULDNG: alifornia Department of Public Health STATEMENT OF DEFENES txl) PROVDERSUPPLER/LA AND PLAN OF ORRETON DENTFATON NUMBER: A (X2) MULTPLE ONSTRUTON B. WNG PRNTED: 11/ FORM A PP RO VED (X3) DATE SURVEY OMPLETED NAME OF PROVDER OR SUPPLER HERTAGE OAKS HOSPTAL STREETADDRESS, r-fl, STATE, ZP ODE SARAMENTO, A (X4) D i SUMMARY STATEMENT OF DEFENES D PROVDER S PLAN OF ORRETON (X5) PREFX (EAH DEFENY MUST BE PREEDED BY FULL PREFX (EAH ORRETVEAT1ON SHOULD BE OMPLETE TAG REGULATORY OR LS DENTFYNG NFORMATON) TAG ROSS-REFERENED TO THE APPROPRATE DATE DEFENY) B OO nitial omments The following reflects the findings of the alifornia Department of Publi Health during the investigauon of two (2) omplaints #A and #A Representing the Department of Public Health: HFEN The inspection was limited to the specific two (2) complaint(s) investigated and does not reflect the findings of a full inspection of the facility. A There were no Volations of regulations identified. A The followng deficienies were identified. S 219j T22 DV5 H2 ART (a) Psychiatric Nursing Sr-v General Requirements 8219 i (a) Written policies and procedures shall be developed and maintained by the director of nursing in onsultation with other appropriate health professionals and administration. Policies shall be approved by the governing body. Procedures shall be approved by the administration and medical staff where such is appropriate. Licensing and ertification Division LABORATORY DRETOR S OR PROVDER/SUPPLER REPRESENTATVE S SGNATURE TTLE (X6)DATE STATE FORM i11 t conlnuatlon sheet 1 of 7
2 ahfornia Deoartment of Public Health PRNTED: 11/19/2013 STATEMENT OF DEFENES (X) PROVDERJSUPPLERLA (X2) MULTPLE ONSTRUTON (X3) DATE SURVEY AND PLAN OF ORRETON DENTFATON NUMBER: A. BULDNG; OMPLETED NAME OF PROVDER OR SUPPLER HERTAGE OAKS HOSPTAL A B. WNG STREETADDRESS, TY, STATE! ZP ODE SARAMENTO, A (X4) D SUMMARY STATEMENT OF DEFENES D PROVDER S PLAN OF ORRETON (X5) PREFX (EAH DEFENY MUST BE PREEDED BY FULL PREFX (EAH ORRETVEAflON SHOULD BE OMPLETE TAG REGULATORY OR LS DENTFYNG NFORMATON) TAG ROSS-REFERENED TO THEAPPROPRATE DATE DEFENY) B 2191 ontinued From page 1 B 219 ontinued from page 1 Licensing and ertificatril D;vsion STATE FORM f continuation sheet 2 of 7
3 STREETADDRESS, PRNTED: 11/19/2913 alifornia Department of Public Health STATEMENT OF DEFENES (Xl) PROVDE5UPPLERLA (X2) MULTPLE ONSTRUTON (X3) DATE SURVEY AND PLAN OF ORRETON DENTFATON NUMBER. A. BULDNG: OMPLETED NAME OF PROViDER OR SUPPLER. HERTAGE OAKS HOSPTAL A j B.WNG 1 10/17/2013 TY, STATE, ZP ODE SARAMENTO, A (X4) D SUMMARY STATEMENT OF DEFENES D PROVDER S PLAN OF ORRETON (X5) PREFX (EAH DEFENY MUST BE PREEDED BY FULL PREFX (EAH ORRETVE ATON SHOULD BE OMPLETE TAG REGULATORY OR LS DENTFYNG NFORPMJON) TAG ROSS-REFERENED TO THE APPROPRATE DATE DEFENY) B 219 ontinued From page 2 B 219 Licensfl9 ana etif:aton DMsion STATE FORM BtDc contraean sheet 3o17
4 PRNTEO: 11/19/2013 ahfornia Department of Public Health STATEMENT OF DEFENES (Xl) PROVDERJSUPPLERAA (X2) MULTPLE ONSTRUTON (X3) DATE SURVEY AND PLAN OF ORRETON DENTFATON NUMBER: A. BULDNG: OMPLETED NAME OF PROViDER OR SUPPLER HERTAGE OAKS HOSPTAL A SWNG STREETADDRESS, TY. STATE, ZP ODE SARAMENTO, A (X4) D SUMM-RY STATEMENT OF DEFENES D PROViDERS PLAN OF ORRETON (5) PREFX (EAH DEFENY MUST BE PREEDED BY FULL PREFX (EAH ORRETVE ATON SHOULD BE DMPETE TAG REGULATORY OR LS DENTFy;NO NFORWJON) TAG ROSS-REFERENED TO THE APPROPRATE DATE DEFENY) B 219 ontinued From page T22 DV5 H2ART (a)(1)(G) Governing B446 Body () The preparation and maintenance of a omplete and accurate medical record for each patient. Lcensing and ertification Division STATE FORM ontinued on page i nhjnuaton sheet 4 of?
5 A. BULDNG: alifornia Denartment of Public Health STATEMENT OF DEFENES AND PLAN OF ORRETON (Xl) PROV1DER/SUPPLERLLA DENTFATON NU1BER. (X2) MULTPLE ONSTRUTON PRNTED: 11/19/2013 X3) DATE SURVEY OMPLETED 0A B. WNG NAME OF PROVDER OR SUPPLER STREETADDRESS, fl, STATE, ZP ODE HERTAGE OAKS HOSPTAL sac4mento A (X4) D SUMMARY STATEMENT OF DEFENES D : PROViDERS PLAN OF ORRETON PREFX (EAH DEFENY MUST BE PREEDED BY FULL PREFX (EAH ORRETVEATON SHOULD BE OMPtETE TAG REGULATORY OR LS DENTFYNG NFORMATON) TAG ROSS-REFERENED TO THEAPPROPRATE An DEFENY) B 446 continued From page 4 B ontinued from page 4 (5) L Licensing and ei STATE FORM f ccn:nuatisr. sheet Sot?
6 HERTAGE OAKS HOSPTAL SARAMENTO, A NNtE OF PROVDER DR SUPPLER STREET ADDRESS, TY, STATE, ZP ODE A SWNG 10/ PRNTED: STATE FORM f nnuauan sheet 6 of 7 Lcensing and ertification Division STATEMENT OF DEFENES (Xl) PROVDER/SUPPLERLA (X2) MULTPLE ONSTRUTON 3) DATE SURVEY AND PLAN OF ORRETON DENTFATON NUMBER: A. BULD[NG: OMPLETED (X4) D SUMMARY STATEMENT OF DEFENES [ PRODERS PLAN OF ORRETON (X5) PREFX (EAH DEFENY MUST BE PREEDED BY FULL PREFX (EAH ORRETVE ATON SHOULD BE OMPLETE TAG REGULATORY OR LS DENTFYNG NFORMATON) TAG ROSS-REFERENED To THE APPROPRATE DATE DEFENY) B 446 B 446 ontinued from page 5 alifornia Department of Public Health
7 PRNTED: 11/19/2013 snforflia Deoartment of Public Health STATEMENT OF DEFENZS (X) PRDVDESUPPUER.1A (X2) MULTPLE ONSTRUTON (X3) DATE SURVEY AND PLAN OF ORRETON DENTFAEON NUMBER: k BUlLDNG: OMPLETED NAME OF PROVDER OR SUPPLER HERTAGE OAKS HOSPTAL A B.WNG STREETADORESS, TY, STATE. ZP ODE 10/17/2013 (X4) D SUMMARY STATEMENT OF DEFEN;ES D PROVDER S PLAN OF ORRETON PREFX (EAH DEFENY MUST BE PREEDED BY FULL PREFX (EAH ORRETiVE ATiON SHOULD BE OMPLETE TAG REGULATORY OR LS DENTFYNG NFORMATON) TAG ROSS REFERENED TO THE APPROPRATE DATE DEFENY) B 446 B 446 Liensing and erliftauon Ovisicn STATE FORM csnlinualion sheel 7 sf7
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STATEMENT OF DEFCENCES AND PLAN OF CORRECTON (X1) PROVDERlSUPPLER/CLlA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A. BULDNG B.WNG NAME OF PROVDER OR SUPPLER STREET ADDRESS, CTY, STATE, lip CODE KASER
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ENTERS FOR MEDIARE & MEDIA SERVIES OMB NO. 0938-0391 (X2) MULTIPLE ONSTRUTION STATEMENT OF DEFIIENIES AND PLAN OF ORRETION NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: JAMES
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