State of California--Health and Human Services Agency Department of Health Care Services CIVIL RIGHTS COMPLIANCE REVIEW (TITLE VI, SECTION 504, ADA) THIS FORM IS TO BE COMPLETED ANNUALLY BY THE ADMINISTRATOR OF THE AGENCY/FACILITY (OR DESIGNEE). 1. a. Name of agency/facility Address (number, street) Administrator County Medi-Cal provider number ZIP code Date Number of employees Number of patients Telephone number ( b. Name of agency/facility staff providing information Title Email Address License number City ) ) ) ) ZIP code Telephone number ( ( c. Name of licensee/parent corporation (if applicable) Address (number, street) Telephone number Telephone number ( State 2. TYPE OF AGENCY/FACILITY General Acute Care Hospital Skilled Nursing Facility County/local health department Acute Psychiatric Hospital Intermediate Care/other Health clinic General Acute Care/Rehabilitation Hospital Intermediate Care Facility/Developmentally Disabled Other (specify) ____________________________________________________________________________________________ 3. TYPE OF CONTROL/OWNERSHIP State government Voluntary nonprofit (other than church) Local government Proprietary Voluntary nonprofit (church) Other (specify) ___________________________ 4. CURRENT CENSUS Licensed bed capacity_________ 5. BILINGUAL SERVICES a. Do you have bilingual persons on staff? Yes No If yes, please identify by name, second language, and shift (use additional paper, if necessary). Language Name of Staff Person Written Spoken Shift (Day, Swing, Grave, etc.) Long-term care beds certified__________ Number of resident/patient rooms __________ Spanish Vietnamese Cambodian Lao Chinese (Cantonese) Chinese (Mandarin) Sign Language Other b. What is your agency's/facility's procedure for identifying the language needs of residents/patients? c. Attach copies of interpreter policies and procedures. Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com DHCS 1051 (04/11) 6. SERVICES FOR DISABLED EMPLOYEES/RESIDENTS Deaf and/or Speech/Hearing Impaired a. Does facility use sign language interpreters? Yes No b. Does facility use text phones (TTYs, formerly TDDs) Yes No c. Does facility use other auxiliary aids for persons with visual, motor, or speech impairments? Yes No If yes, identify aid utilized: _________________________________________________________________________________ d. Identify community resources for interpreter services: ___________________________________________________________ Mobility Impaired a. Have public telephones been lowered for use by persons in wheelchairs? Yes No Yes No b. Are drinking fountains accessible to persons in wheelchairs? c. Are public restrooms accessible to persons in wheelchairs? Yes No 7. ETHNIC/DISABILITY/GENDER COMPOSITION OF STAFF (Enter number of staff in each category.) Type of Occupation Managerial Professional Technicians Office/Clerical Service Workers Laborers White Black Hispanic Asian Filipino Native American Disabled Male Female 8. RESIDENT CHARACTERISTICS a. Current number of residents/patients:________ b. Is use of your agency/facility limited to membership in a defined group? (e.g., fraternal organization, religious denomination, employees of a corporation, union, etc.) Yes No If yes, attach the membership requirements and any other material that further explains the limitation. c. Estimate the number of patients or beneficiaries belonging to the following groups admitted during the past year. _______ White _______ Black _______ Filipino _______ Other _______ Female _______ Native American _______ Hispanic _______ Asian _______ Male d. What is the approximate age range of the residents? ____________________ e. If your agency/facility assigns rooms to residents/patients, complete the following information. Indicate below the number of minority group patients in today's census by type of room assignment according to the following breakdown: White Number of residents in single rooms or alone Number of minority residents in semiprivate rooms or wards having only minority persons Number of minority residents in semiprivate rooms or wards with one or more nonminority persons TOTAL Black Hispanic Asian Native American Filipino Other 9. ETHNIC COMPOSITION OF THE GENERAL SERVICE POPULATION. Retrieve this data from your county census bureau. _____% White _____ % Native American _____ % Black ____ % Asian ____ % Hispan _____% Filipino _____ Other 10. LANGUAGE GROUP COMPOSITION OF THE GENERAL SERVICE POPULATION (List by percentage and list only those language groups comprising 5 percent or more of the population.) Retrieve this data from your county census bureau. _____ Spanish _____ Vietnamese _____ Cambodian _____ Lao _____ Cantonese _____ Mandarin _____ Sign Language _____ Other (describe) ______________ DHCS 1051 (04/11) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 11. ETHNIC/DISABILITY COMPOSITION OF ADVISORY BOARD/BOARD OF DIRECTORS Describe the method used to recruit and select board members. (Provide a copy of your eligibility criteria for board membership.) List the facility's Advisory Boards and/or Board of Directors and state the ethnic and disability composition of each Advisory Board/Board of Directors. Advisory Board/Board of Directors Ethnic/Disability Composition 12. EQUAL ACCESS PRACTICES a. What is your agency's/facility's policy on admission of persons with HIV/AIDS? (Use additional paper, if necessary.) b. Does your facility have any restrictions on admissions of persons with HIV/AIDS? . . . . . . . . . . . . . . . . . . . . . . . c. Do you have policies and procedures for caring for persons with HIV/AIDS? . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Yes No No d. What records are kept by your facility about admission inquiries? ____________________________________________________ e. Have any prospective residents diagnosed with HIV/AIDS been denied admission or care and treatment during the last 12 months? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, please explain why (use additional paper, if necessary): Yes No f. Do you have policies and procedures governing the number of heavy care residents you can care for at any one time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . Yes No g. Have you ever denied admission or care an