Other·February 7, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for investgation of Entity Reported event #CA00499136. The findings in this report are limited to a specific incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor #25962 Health Facility Evaluator Nurse. The census of the facility was 122 and one bedhold, the sample size was 3. NO DEFICIENCY FOUND FOR ERI # CA00499136 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FJ8X11 Facility ID: CA010000046 If continuation sheet 1 of 1