Other·June 21, 2018

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 for the California Department of Public Health during an abbreviated standard survey for the investigation of one complaint. Complaint number CA 00576242. Representing the California Department of Public Health: Surveyor 37537, HFEN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. No deficiencies were issued for complaint number CA 00576242. 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: R7GU11 Facility ID: CA240000153 If continuation sheet 1 of 1