Evaluations and Deficiencies: Facilities

Title 22 §87756

Reasons for Evaluations

  • All RCFEs subject to unannounced visits by CCLD.
  • Inspections are required every three years, as of 2017.  
  • Special circumstances (i.e. probationary license, etc) may require more frequent visits.
  • CCLD is required to visit facilities as often as necessary to ensure quality care is provided.
  • CCLD shall conduct annual unannounced visits to no less than 20% of facilities.
  • Visits for complaint investigations are different than visits for facility evaluations. 

Facility evaluations are reported on LIC 809s.

Reasons for Deficiencies

A deficiency is defined by Title 22 as "any failure to comply with any provision of the act governing RCFEs and any other applicable regulations". 

If a deficiency is found during an evaluation, LPAs are required to issue a notice of deficiency.  However, if the deficiency is deemed minor and is corrected during the visit a notice of deficiency need not be issued according to Title 22. 

If a deficiency is noted, the LPA must meet with the person in charge of the facility and discuss the noted deficiencies and together they must develop a plan for correcting each deficiency.  The plan of correction must then be included on the notice of deficiency.  The notice is then signed by both parties and should then be posted in a conspicuous location in the facility.

Viewing deficiencies

Copies of all notices of deficiencies are kept at the facility (as well as at CCLD in the facility's individual file). 

Every RCFE must: