Violation

California Code § 87458(c)(1)Physical Exam Records

How CCLD inspectors cite this regulation, what providers do to stay clear of it, and where it appears in the public record.

Type B, generalAffects rcfe41 facilities cited in the last 90 days

ℹ️ Educational reference based on public CCLD inspection records. Not legal or compliance advice. Verify requirements with official sources. Full disclaimer →

Regulation text

What California Code § 87458(c)(1) actually says

California Code § 87458(c)(1)

A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:

From the field

What providers tell us about this citation

Based on community experience, not official guidance.

41 California RCFEs were cited for incomplete physical exam documentation. LPAs pull resident files within the first hour of an inspection and check for the physician's diagnosis on every admission form. Assign one staff member to track outstanding exam reports weekly, because a single missing diagnosis triggers a Type B citation on the spot.

By the numbers

41^*CCLD: facilities cited in the last 90 days
11^*CCLD: counties where this citation appeared
--^*CCLD: rank among most-common citations
Trajectory: Steady

41 facilities were cited for this in the last 90 days. See if yours is one of them.

Check a facility

What other providers do

Common practices to stay clear of Physical Exam Records

Common practices shared by providers. Confirm requirements with your licensing analyst.

Common practices

Obtain a physical examination report with the physician's diagnosis before or at the time of admission.
Include all examination elements specified in Section 87458(c)(1) in the resident's file.
Keep the exam report accessible for LPA review during inspections and annual visits.
Update the record when a significant change in the resident's condition requires a new diagnosis.

What to avoid

Admitting a resident before the physical exam form is returned by the physician and leaving the file incomplete for weeks.
Filing the exam report but missing the physician's diagnosis, which Section 87458(c)(1) specifically requires.
Failing to obtain an updated exam after a hospitalization or significant health change.

Regional record

Where this citation appeared in the past 90 days

Citation counts and rates by California county, drawn from CCLD inspection records.

Regional citations for Physical Exam Records, last 90 days
County	Citations	Facilities	Citation rate
Los Angeles	17	--	--
Orange	9	--	--
San Bernardino	5	--	--
Riverside	2	--	--
San Diego	2	--	--
Madera	1	--	--
Merced	1	--	--
Alameda	1	--	--
San Mateo	1	--	--
Sacramento	1	--	--

SOURCE

*CCLD: California Community Care Licensing Divisionviolation_citations2026-05-30Updated weekly

FAQ

Frequently asked questions

Answers based on public CCLD data and regulation text. May not reflect recent changes.

What is a physical examination documentation violation under Section 87458(c)(1)?

Title 22, Section 87458(c)(1) requires that each RCFE resident have a physical examination report on file showing the licensed medical professional's diagnosis and exam results. The document must cover the specific health elements the regulation lists. Without it, the community cannot verify that the resident's care needs match the level of care the facility is approved to provide.

How common is this violation in California assisted living?

According to California CCLD inspection records, 41 California RCFEs were cited for noncompliance with Section 87458(c)(1). These citations are classified as Type B, meaning the deficiency creates a potential rather than immediate risk to residents. Los Angeles County accounted for 17 of these citations, followed by Orange County with 9.

What happens if an RCFE is cited for missing physical exam documentation?

A Type B citation under Section 87458(c)(1) requires the facility to submit a plan of correction to CCLD within the deadline set by the Licensing Program Analyst. Type B citations carry civil penalties, though lower than Type A citations. The LPA may conduct a follow-up visit to confirm the missing documentation has been obtained and filed.

How do I fix or prevent physical examination documentation violations?

Request the completed physical exam form from the resident's physician before or on the admission date. Set up a tracking system that flags any admission where the exam report is still outstanding after 48 hours. Assign a staff member to follow up with the physician's office directly. LPAs routinely pull a sample of resident files during inspections, so keep these documents organized and accessible.

Does a physical examination documentation violation affect my RCFE license?

Yes. Repeated Type B citations for incomplete admission records can trigger increased CCLD scrutiny, including more frequent inspections. CCLD records show that patterns of documentation noncompliance may lead to conditions placed on the facility's license. Operators should treat each citation as a signal to audit all current resident files for the same gap.

Related violations

Other citations in this regulation family

This information is educational and does not constitute legal advice. Consult a licensed residential care compliance consultant for guidance specific to your facility. Citation data is sourced from California Community Care Licensing Division public records and is refreshed regularly.

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