Section 1 of 13 in this document
Kern County Ombudsman Logo

Facility Visit Report

Ombudsman Name

Date and Time of the Visit

Date Picker

Facility Type

Section 2 of 13 in this document

Staff Updates

Did you notice any changes in facility staff or new personnel during your visit?

First Staff Update

Facility Staff Name

Position

Did you notice any other changes in facility staff or new personnel during your visit?

Section 3 of 13 in this document

Staff Updates (cont.)

Second Staff Update

Facility Staff Name

Position

Did you notice any other changes in facility staff or new personnel during your visit?

Section 4 of 13 in this document

Staff Updates (cont.)

Third Staff Update

Facility Staff Name

Position

Section 5 of 13 in this document

Facility Resident Council Updates

Did you meet with the resident council during your visit?

Resident Council Contact

Resident Council Name

Did you get invited to the resident council meeting by the resident council?

Did you meet with any additional members of the resident council during your visit?

Section 6 of 13 in this document

Facility Resident Council Updates (cont.)

Second Resident Council Contact

Resident Council Name

Did you get invited to the resident council meeting by the resident council?

Did you meet with any additional members of the resident council during your visit?

Section 7 of 13 in this document

Facility Resident Council Updates (cont.)

Third Resident Council Contact

Resident Council Name

Did you get invited to the resident council meeting by the resident council?

Section 8 of 13 in this document

Trip Summary

Did you notice any Ombudsman posters during your visit?

Location of ombudsman posters (Check all that apply.)

Please write a detailed paragraph capturing your observations during your visit.

Describe the sights around you, the scents in the air, the hygiene of the residents, the cleanliness of the facility, the sounds that surrounded you, the quality of the lighting, and the temperature you experienced. Aim to paint a vivid picture of the atmosphere you encountered during your visit.

Section 9 of 13 in this document

Information and Assistance

During your visit, did you talk to someone about the Ombudsman Program, the rights of residents, available resources, and/or issues related to care?

First Person

Was the individual you spoke to a Resident of the facility, a Facility Staff member, or a Visitor?

Resident's Gender

Is the resident over 60 years old?

Ethnicity

Please provide the name of the individual you spoke with during your visit.

Was a brochure for the ombudsman program provided?

Please select all the topics that were discussed with the individual during your visit.

Did you talk to anyone else during your visit?

Section 10 of 13 in this document

Information and Assistance (cont.)

Second Person

Was the individual you spoke to a Resident of the facility, a Facility Staff member, or a Visitor?

Resident's Gender

Is the resident over 60 years old?

Ethnicity

Please provide the name of the individual you spoke with during your visit.

Was a brochure for the ombudsman program provided?

Please select all the topics that were discussed with the individual during your visit.

Did you talk to anyone else during your visit?

Section 11 of 13 in this document

Information and Assistance (cont.)

Third Person

Was the individual you spoke to a Resident of the facility, a Facility Staff member, or a Visitor?

Resident's Gender

Is the resident over 60 years old?

Ethnicity

Please provide the name of the individual you spoke with during your visit.

Was a brochure for the ombudsman program provided?

Please select all the topics that were discussed with the individual during your visit.

Section 12 of 13 in this document

Additional Files

Please upload any photos or documents you collected during your visit below.