Form Lic 613c-2 - Personal Rights In Privately Operated Residential Care Facilities For The Elderly

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERSONAL RIGHTS
IN PRIVATELY OPERATED
RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
EXPLANATION: This form describes the personal rights of each person admitted to
a privately operated Residential Care Facility for the Elderly (RCFE). This form also
provides the complaint procedures for a resident and the resident’s responsible person.
The California Code of Regulations, Title 22, requires that a licensee personally advise
any resident and the resident’s responsible person or conservator (if any) of the
personal rights described on this form when a resident is admitted to a RCFE. The
facility staff and the resident’s responsible person or conservator (if any) must explain
these rights to the resident in a manner appropriate to the resident’s needs.
This personal rights form must be reviewed, completed, and signed and dated by each
resident and responsible person or conservator (if any) upon admission to a RCFE.
The licensee is required to provide the resident and responsible person or conservator
(if any) with a complete written copy of these rights. The signed copy of these rights
shall be retained in the resident’s file maintained by the licensee.
The licensee is also required to post these rights in a prominent area accessible to
residents, residents’ responsible persons, and the public.
These personal rights must be posted in English and in any other language(s) in which
at least 5% of the residents can only read that other language(s).
LIC 613C-2 (7/17) (CONFIDENTIAL)
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