Form Lic 613C – Fill Out and Use This PDF

STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PERSONAL RIGHTS

RESIDENTIAL CARE FACILITIES FOR THE ELDERLY

EXPLANATION: The California Code of Regulations, Title 22 requires that any person admitted to a facility must be advised of his/her personal rights. Facilities licensed for seven (7) or more are also required to post these rights in areas accessible to the public. Consequently, this form is designed to meet both the needs of persons admitted to facilities and the facility owners who are required to post these rights.

This form describes the personal rights to be afforded each person admitted to a facility. This form also provides the complaint procedures for the resident and the resident’s responsible person. The facility staff, resident’s responsible person or conservator must explain these rights in a manner appropriate to the resident’s ability.

This form is to be reviewed, completed and signed by each resident, and/or responsible person (if any), or conservator upon admission to the facility. The resident and/or responsible person or conservator also has the right to receive a completed copy of the originally signed form. This originally signed copy shall be retained in the resident’s file, which is maintained by the facility.

RESIDENT OR CONSERVATOR AND RESPONSIBLE PERSON

Upon satisfactory and full disclosure of the personal rights, complete the following:

I/we have been personally advised and have received a copy of the personal rights contained in the California Code of Regulations, Title 22.

(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)
(TITLE OF THE RESPONSIBLE PERSON OR CONSERVATOR)

THE RESIDENT AND/OR THE RESPONSIBLE PERSON OR CONSERVATOR HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:

NAME

To report known or suspected elder abuse, contact the Statewide Ombudsman Toll Free 24-hour CRISIS line at 1-800-231-4024. Local Ombudsman’s Office Telephone Number _______________________________.

LIC 613C (7/05) (Confidential)

PERSONAL RIGHTS

RESIDENTIAL CARE FACILITIES FOR THE ELDERLY

Explanation: Each resident shall have rights which include, but are not limited to, the following:

(1)To be accorded dignity in his/her personal relationships with staff, residents, and other persons.

(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

(3)To be free from cor poral or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature, such as withholding of monetary allowances or interfering with daily living functions such as eating or sleeping patterns or elimination.

(4)To be informed by the licensee of the provisions of law regarding complaints and of procedures to confidentially register complaints, including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency.

(5)To have the freedom of attending religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis.

(6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit the establishment of house rules, such as the locking of doors at night, for the protection of residents; nor does it prohibit, with permission of the licensing agency, the barring of windows against intruders.

(7)To visit the facility prior to residence along with his/her family and responsible persons.

(8)To have his/her family or responsible persons regularly informed by the facility of activities related to his/her care or services including ongoing evaluations, as appropriate to the resident’s needs.

(9)To have communications to the facility from his/her family and responsible persons answered promptly and appropriately.

LIC 613C (7/05) (Confidential)

(10)To be informed of the facility’s policy concerning family visits and other communications with residents. This policy shall encourage regular family involvement and provide ample opportunities for family partici- pation in activities at the facility.

(11)To have his/her visitors, including ombudspersons and advocacy rep- resentatives permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.

(12)To wear his/her own clothes; to keep and use his/her own personal possessions, including his/her toilet articles; and to keep and be allowed to spend his/her own money.

(13)To have access to individual storage space for private use.

(14)To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls.

(15)To mail and receive unopened correspondence in a prompt manner.

(16)To receive or reject medical care, or other services.

(17)To receive assistance in exercising the right to vote.

(18)To move from the facility.

Reference: California Code of Regulations - Title 22, Section 87572, Residential Care Facilities for the Elderly

LIC 613C (7/05) (Confidential)