Form LIC613c-2 "Personal Rights in Privately Operated Residential Care Facilities for the Elderly" - California

What Is Form LIC613c-2?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2017;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form LIC613c-2 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form LIC613c-2 "Personal Rights in Privately Operated Residential Care Facilities for the Elderly" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERSONAL RIGHTS
IN PRIVATELY OPERATED
RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
EXPLANATION: This form describes the personal rights of each person admitted to
a privately operated Residential Care Facility for the Elderly (RCFE). This form also
provides the complaint procedures for a resident and the resident’s responsible person.
The California Code of Regulations, Title 22, requires that a licensee personally advise
any resident and the resident’s responsible person or conservator (if any) of the
personal rights described on this form when a resident is admitted to a RCFE. The
facility staff and the resident’s responsible person or conservator (if any) must explain
these rights to the resident in a manner appropriate to the resident’s needs.
This personal rights form must be reviewed, completed, and signed and dated by each
resident and responsible person or conservator (if any) upon admission to a RCFE.
The licensee is required to provide the resident and responsible person or conservator
(if any) with a complete written copy of these rights. The signed copy of these rights
shall be retained in the resident’s file maintained by the licensee.
The licensee is also required to post these rights in a prominent area accessible to
residents, residents’ responsible persons, and the public.
These personal rights must be posted in English and in any other language(s) in which
at least 5% of the residents can only read that other language(s).
LIC 613C-2 (7/17) (CONFIDENTIAL)
PAGE 1 OF 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERSONAL RIGHTS
IN PRIVATELY OPERATED
RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
EXPLANATION: This form describes the personal rights of each person admitted to
a privately operated Residential Care Facility for the Elderly (RCFE). This form also
provides the complaint procedures for a resident and the resident’s responsible person.
The California Code of Regulations, Title 22, requires that a licensee personally advise
any resident and the resident’s responsible person or conservator (if any) of the
personal rights described on this form when a resident is admitted to a RCFE. The
facility staff and the resident’s responsible person or conservator (if any) must explain
these rights to the resident in a manner appropriate to the resident’s needs.
This personal rights form must be reviewed, completed, and signed and dated by each
resident and responsible person or conservator (if any) upon admission to a RCFE.
The licensee is required to provide the resident and responsible person or conservator
(if any) with a complete written copy of these rights. The signed copy of these rights
shall be retained in the resident’s file maintained by the licensee.
The licensee is also required to post these rights in a prominent area accessible to
residents, residents’ responsible persons, and the public.
These personal rights must be posted in English and in any other language(s) in which
at least 5% of the residents can only read that other language(s).
LIC 613C-2 (7/17) (CONFIDENTIAL)
PAGE 1 OF 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RESIDENT AND RESPONSIBLE PERSON OR CONSERVATOR (IF ANY): Upon
satisfactory and full disclosure of the personal rights described on this form, complete
the following:
I/We have been personally advised and have received a copy of the personal
rights in section 1569.269 of the Health and Safety Code and the personal rights
in the California Code of Regulations, Title 22, section 87468 described on this
form.
_____________________________________________________________________
(PRINT THE NAME OF THE FACILITY)
(PRINT THE ADDRESS OF THE FACILITY)
_____________________________________________________________________
(PRINT THE NAME OF THE RESIDENT)
_____________________________________________________________________
(SIGNATURE OF THE RESIDENT)
(DATE)
_____________________________________________________________________
(SIGNATURE OF THE RESPONSIBLE PERSON OR CONSERVATOR, IF ANY)
_____________________________________________________________________
(TITLE OF THE RESPONSIBLE PERSON OR CONSERVATOR, IF ANY)
The resident and responsible person or conservator (if any) have the right to be
informed of the appropriate licensing agency to contact regarding complaints,
which is:
_____________________________________________________________________
NAME
_____________________________________________________________________
ADDRESS
_____________________________________________________________________
CITY
ZIP CODE
AREA CODE/TELEPHONE
NUMBER
To report known or suspected elder abuse, please contact the Statewide
Ombudsman Toll Free 24-hour CRISIS line at 1-800-231-4024.
Local Ombudsman’s Office Telephone Number: ____________________________
LIC 613C-2 (7/17) (CONFIDENTIAL)
PAGE 2 OF 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERSONAL RIGHTS
IN PRIVATELY OPERATED
RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
EXPLANATION: Each resident of a Residential Care Facility for the Elderly shall have
all of the following rights, which are in Health and Safety Code section 1569.269:
(1)
To be accorded dignity in their personal relationships with staff, residents, and
other persons.
(2)
To be granted a reasonable level of personal privacy in accommodations,
medical treatment, personal care and assistance, visits, communications,
telephone conversations, use of the Internet, and meetings of resident and family
groups.
(3)
To confidential treatment of their records and personal information and to
approve their release, except as authorized by law.
(4)
To be encouraged and assisted in exercising their rights as citizens and as
residents of the facility. Residents shall be free from interference, coercion,
discrimination, and retaliation in exercising their rights.
(5)
To be accorded safe, healthful, and comfortable accommodations, furnishings,
and equipment.
(6)
To care, supervision, and services that meet their individual needs and are
delivered by staff that are sufficient in numbers, qualifications, and competency
to meet their needs.
(7)
To be served food of the quality and in the quantity necessary to meet their
nutritional needs.
(8)
To make choices concerning their daily life in the facility.
(9)
To fully participate in planning their care, including the right to attend and
participate in meetings or communications regarding the care and services to
be provided in accordance with Section 1569.80, and to involve persons of their
choice in the planning process. The licensee shall provide necessary information
and support to ensure that residents direct the process to the maximum extent
possible, and are enabled to make informed decisions and choices.
LIC 613C-2 (7/17) (CONFIDENTIAL)
PAGE 3 OF 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
(10) To be free from neglect, financial exploitation, involuntary seclusion, punishment,
humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
(11) To present grievances and recommend changes in policies, procedures, and
services to the staff of the facility, the facility’s management and governing
authority, and to any other person without restraint, coercion, discrimination,
reprisal, or other retaliatory actions. The licensee shall take prompt actions to
respond to residents’ grievances.
(12) To contact the State Department of Social Services, the long-term care
ombudsman, or both, regarding grievances against the licensee. The licensee
shall post the telephone numbers and addresses for the local offices of the
State Department of Social Services and ombudsman program, in accordance
with Section 9718 of the Welfare and Institutions Code, conspicuously in the
facility foyer, lobby, residents’ activity room, or other location easily accessible to
residents.
(13) To be fully informed, as evidenced by the resident’s written acknowledgment,
prior to or at the time of admission, of all rules governing residents’ conduct and
responsibilities. In accordance with Section 1569.885, all rules established by
a licensee shall be reasonable and shall not violate any rights set forth in this
chapter or in other applicable laws or regulations.
(14) To receive in the admission agreement a comprehensive description of the
method for evaluating residents’ service needs and the fee schedule for the
items and services provided, and to receive written notice of any rate increases
pursuant to Sections 1569.655 and 1569.884.
(15) To be informed in writing at or before the time of admission of any resident
retention limitations set by the state or licensee, including any limitations or
restrictions on the licensee’s ability to meet residents’ needs.
(16) To reasonable accommodation of individual needs and preferences in all aspects
of life in the facility, except when the health or safety of the individual or other
residents would be endangered.
(17) To reasonable accommodation of resident preferences concerning room and
roommate choices.
LIC 613C-2 (7/17) (CONFIDENTIAL)
PAGE 4 OF 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
(18) To written notice of any room changes at least 30 days in advance unless the
request for a change is agreed to by the resident, required to fill a vacant bed, or
necessary due to an emergency.
(19) To share a room with the resident’s spouse, domestic partner, or a person of
resident’s choice when both spouses, partners, or residents live in the same
facility and consent to the arrangement.
(20) To select their own physicians, pharmacies, privately paid personal assistants,
hospice agency, and health care providers, in a manner that is consistent
with the resident’s contract of admission or other rules of the facility, and in
accordance with this act.
(21) To have prompt access to review all of their records and to purchase
photocopies. Photocopied records shall be promptly provided, not to exceed two
business days, at a cost not to exceed the community standard for photocopies.
(22) To be protected from involuntary transfers, discharges, and evictions in violation
of state laws and regulations. Facilities shall not involuntarily transfer or evict
residents for grounds other than those specifically enumerated under state law or
regulations, and shall comply with enumerated eviction and relocation protections
for residents. For purposes of this paragraph, “involuntary” means a transfer,
discharge, or eviction that is initiated by the licensee, not by the resident.
(23) To move from a facility.
(24) To consent to have relatives and other individuals of the resident’s choosing visit
during reasonable hours, privately and without prior notice.
(25) To receive written information on the right to establish an advanced health care
directive and, pursuant to Section 1569.156, the licensee’s written policies on
honoring those directives.
(26) To be encouraged to maintain and develop their fullest potential for independent
living through participation in activities that are designed and implemented for
this purpose, in accordance with Section 87219 of Title 22 of the California Code
of Regulations.
LIC 613C-2 (7/17) (CONFIDENTIAL)
PAGE 5 OF 8