& BULDNG: alifornia Department of Public Health STATEMENT OF DEFENES txl) PROVDERSUPPLER/LA AND PLAN OF ORRETON DENTFATON NUMBER: A030000522 (X2) MULTPLE ONSTRUTON B. WNG PRNTED: 11/1912013 FORM A PP RO VED (X3) DATE SURVEY OMPLETED 1011712013 NAME OF PROVDER OR SUPPLER HERTAGE OAKS HOSPTAL STREETADDRESS, r-fl, STATE, ZP ODE SARAMENTO, A 95841 (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 8 000 The following reflects the findings of the alifornia Department of Publi Health during the investigauon of two (2) omplaints #A00243046 and #A00289870. Representing the Department of Public Health: HFEN 26367 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. A00289870 - There were no Volations of regulations identified. A00243046 - The followng deficienies were identified. S 219j T22 DV5 H2 ART3-71213(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 6899 462i11 t conlnuatlon sheet 1 of 7
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 A030000822 B. WNG STREETADDRESS, TY, STATE! ZP ODE SARAMENTO, A 95841 1011712013 (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 462111 f continuation sheet 2 of 7
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 A030000822 j B.WNG 1 10/17/2013 TY, STATE, ZP ODE SARAMENTO, A 95841 (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 462111 contraean sheet 3o17
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 A030000822 SWNG STREETADDRESS, TY. STATE, ZP ODE SARAMENTO, A 95841 1011712013 (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 3 8219. 84461 T22 DV5 H2ART6-71501(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 5 46211 i nhjnuaton sheet 4 of?
A. BULDNG: 12013 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 0A030000822 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 96841 446 ontinued from page 4 (5) L Licensing and ei STATE FORM 462111 f ccn:nuatisr. sheet Sot?
HERTAGE OAKS HOSPTAL SARAMENTO, A 95841 NNtE OF PROVDER DR SUPPLER STREET ADDRESS, TY, STATE, ZP ODE A030000822 SWNG 10/1712013 PRNTED: 1111912013 STATE FORM 462111 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
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 A030000822 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 452111 csnlinualion sheel 7 sf7