Kansas City Finance

Aug 2 2017

How to File a Complaint Against a Nursing Home – CANHR #canhr, #ccrc, #long #term


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Licensing and Certification District (LCD) Office Addresses

Find the county office for a particular facility by using the table above.

  1. East Bay District Office
    850 Marina Bay Parkway, Bldg. P, 1st Fl,
    Richmond, CA 94804-6403
    (510) 620-3900 Toll Free (866) 247-9100
    Fax: (510) 620-3924, (510) 620-5820
  2. Bakersfield Office
    4540 California Avenue, Suite 200 Bakersfield, CA 93309
    (661) 336-0543 Toll Free (866) 222-1903
    Fax: (661) 336-0529
  3. Chico Office
    126 Mission Ranch Blvd. Chico, CA 95926
    (530) 895-6711 / (800) 554-0350
    Fax: (530) 895-6723
  4. San Francisco Office
    150 North Hill Drive, Suite 22, Brisbane, CA 94005
    (415) 330-6353 / (800) 554-0353
    Fax: (415) 330-6350
  5. Fresno Office
    285 W. Bullard, Suite 101, Fresno, CA 93704
    (559) 437-1500 / (800) 554-0351
    Fax: (559) 437-1555
  6. Los Angeles Office
    12440 E. Imperial Highway, Room 522
    Norwalk, CA 90650 (562) 345-6884 / (800) 228-1019
    Fax: (562) 409-5096
  7. Santa Rosa/ Redwood Coast District Office
    2170 Northpoint Parkway, Santa Rosa, CA 95407
    (707) 576-6775 / Toll Free: (866) 784-0703
    Fax: (707) 576-2037
  8. Orange County Office
    681 S. Parker Street, Ste. 200, Orange, CA 92868
    (714) 567-2906 / (800) 228-5234
    Fax: (714) 567-2815
  9. Riverside Office
    625 East Carnegie Dr. Ste. 280
    San Bernardino, CA 92408
    (909) 388-7170 Toll Free: (888) 354-9203
    Fax: (909) 388-7174
  10. Sacramento Office
    3901 Lennane Dr. Ste. 210, Sacramento, CA 95834
    (916) 263-5800 / (800) 554-0354
    Fax: (916) 263-5840
  11. San Bernardino Office
    464 West Fourth St. Ste. 529,
    San Bernardino, CA, 92401
    (909) 383-4777 / (800) 344-2896
    Fax: (909) 888-2315
  12. San Diego North
    7575 Metropolitan Dr. Ste 104, San Diego, CA 92108
    (619) 278-3700 / (800) 824-0613
    Fax: (619) 278-3725
  13. San Diego South
    7575 Metropolitan Dr. Ste. 211, San Diego, CA 92108
    (619) 688-6190 / Toll Free (866) 706-0759
    Fax: (619) 688-6444
  14. San Jose Office
    100 Paseo de San Antonio, Ste. 235,
    San Jose, CA 95113
    (408) 277-1784 / (800) 554-0348
    Fax: (408) 277-1032
  15. Ventura Office
    1889 N. Rice Avenue, Ste. 200, Oxnard, CA 93030
    (805) 604-2926 / (800) 547-8267
    Fax: (805) 604-2997

Sample Nursing Home Complaint Form

The form below may be used as a guide for what to include when filing a complaint.

Date Completed: _______________

Name of person filing complaint: _________________________________

City: __________________________ State: _______ Zip: ____________

Daytime phone: ___________________ Evening: ____________________

Name of facility: ______________________________________________

Address of facility: ____________________________________________

City: ___________________________ State: ______ Zip: ____________

Name of NH resident on whose behalf the complaint is made:

Date(s) of incident: _______________

Shift(s) when incident(s) occurred, if known:

Witnesses (including health care professionals):

Records that should be examined:

Name of staff person(s) if violation involves action or lack of action by staff:

Mark the following spaces that apply:

I have sent a copy of my complaint to the appropriate Licensing and Certification district office of the California Department of Public Health.

I am also sending CANHR a copy of this complaint.

I have sent the Ombudsman Program a copy of this complaint.

I am sending my California State Legislator a copy of this complaint.

I am sending a copy to the Attorney General.

I am sending a copy to the Attorney General.

I want to know the name of the investigator assigned to this complaint.

I want to talk with the investigator before s/he goes to the facility for an onsite visit.

I want to accompany the investigator to the facility when the complaint investigation is being done.

I want to remain anonymous. I do not want my name or identity known to the nursing facility.

I want a copy of the final complaint report, and notice of my rights if I am not satisfied with your findings.

Page Last Modified: May 17, 2017

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