University of California Irvine Medical Center -IJ
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH
STATEMENT OFDEFICIENCIES ANDPLANOF C:ORRECTI ON
(X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER
050348
(X2! MULTIPLECDNSTRUCTION
~- BULDING B.IN!NG
N~ME OF PROIADER OR SUPPLIER
University of California Irvine Medical Center
STREET ADDRESS. !,;ITY, STATE. ZIPCODE
101 The City Dr S, Orange .CA 92868-3201 ORANGE COUNTY
,X3) DATE SURVEY COMPLETED
02/06/20 18
(X4) D PREii TAG
SUMMARY STATEMENT OF DEICIENCIES (EACH DEFICIENCY MUST BE PREC.EEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION,
The following reflects the findings of the Department of Public Health during an inspection visit:
D PREFIX
TAG
PROVIDER'S PLAN OF CORRfCTION (EACH CORRECTIVE ACTION SHOULD BE CROSS? REFERENCED TO THE APPROPRIAT E DEFICIENCY)
(X~l COMPLETE
DATE
Complaint Intake Number: CA00562668 - Substantiated
Representing the DepartmentofPublic Health: Surveyor 10#3043. HFEN
The inspection was limited to the specific facility event investigated and does not represent the findings of a fu II inspection ofthe facility .
Health and Safety Code Section 1280.3(9): For
purposes of this section "immediate jeopardy"
means a situation in which the licensee's
noncompliance with one or more requirements of
licensure has caused. or is likely to cause.serious
injury or death to the patient.
--_,
Health and Safety Code Section 1279.1 (c):The
facility shall inform the patient or the party
Ul
responsible for the patient of the adverse event by
("')
the time the report is made.
I ['
The CDPH verified that the facility informed the patient or the party responsible for the patient ofthe adverse event by the time the report was made.
Health and Safety Code 1280.3 (g): For purposes of this section. "immediate jeopardy" means a situation in which the licensee's noncompliance with one or more requirements of licensure has caused, oris likely to cause, serious injury or to the patient.
Health and Safety Code 1279.1 (b): For purposes of
Event ID:W03611 - -
10/3/2018
2:58:31PM
' ' O R P R O V I D E R / S U P PL I E R R E P R E S E N T A T I V E ' S S I G N A T U R E
TITLE
(X6) DATE
Chief Executive Officer By signing lhis ument lam acl ................
................
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