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Facility Site Review Resources


icon PDF Welcome Letter/Pre-Audit Checklist    FSR Training Application

Facility Site Review Forms


Please click on a form below to view a PDF printable version.
The files below are in PDF format(icon PDF)


Department of Health Care Services Review Tools and Guidelines


 Facility Site Review Tool
 Facility Site Review Guideline
 Medical Record Review Tool
 Medical Record Review Guideline
Interim Review of Critical Elements at 18 months
ADA Seniors and Persons with Disabilities (SPD) tool

Facility Forms


 Members Rights and Responsibilities Poster (English)
 Members Rights and Responsibilities Poster (Spanish)
 Mandatory Annual Staff Training Completion Form
 Staff Language Capabilities Form
 Health Education Print Material Order Form
 Grievance Form (English)
 Grievance Form (Spanish)
 Grievance Information (Provider Manual)

Facility Logs


 Autoclave Cleaning log
 Autoclave Load log
 Cleaning Schedule (Mandatory Initial Page)
 Emergency Drugs Inventory Log
 Emergency Pre-Calculated Dosage Chart
 Grievance Log
 HemoCue Log
 Monthly Medication Check Log
 Monthly Medication Verification and Equipment Log
 Referral Log
 Refrigerator-Freezer Temperature Log
 Sharps Injury Log

Medical Records - Frequently Needed Forms


 Adult Preventive Care Flow Sheet
 Adult TB Risk Assessment (English & Spanish)
 Adult and Peds TB Risk Assessment (English & Spanish)
 Advanced Directive Policy & Procedure
 Advanced Directive Information Sheet English
 Advanced Directive Information Sheet Spanish
 Advanced Directive Document English
 Advanced Directive Document Spanish
 Medication List
 Primary Language Spoken by Member Form (English & Spanish)
 Problem List
 Registration Form (English & Spanish)
 Vision-Hearing Screening Form

If you experience any difficulties, please contact the administrator:

1(800) 526-8196 X120117

Medicare callout

Medicare Now Available!


Are you eligible?

Molina now offers Medicare plans that provide all of the benefits covered under original Medicare and more.