Cal. Health & Safety Code § 7158.1

(a) As a part of its ongoing audit and review process, the Licensing and Certification Division of the State Department of Health Services shall audit for the existence of organ and tissue procurement procedures for all inpatient hospital facilities. The audit shall include a determination of whether these procedures are in place in the facility, whether the procedures are operational and functioning, and whether the procedures are being used. The department shall not be required to audit for the effectiveness of the procedures. No additional audits shall be required for purposes of this section. Instead, the department shall add an organ and tissue audit element to its regular ongoing audits of inpatient facilities.
(b) For purposes of this chapter, “organ and tissue procurement procedures” shall include protocols required to be developed pursuant to Section 7184. The audit criteria shall, at a minimum, include all of the following:
1. (1) That the protocols have been developed.
2. (2) That the protocols are operational.
3. (3) That notification requirements to next of kin or other individuals as set forth in Section 7151 and to organ procurement organizations are within a timeframe that is consistent with the maintenance of the organs for the purpose of transplantation.
(c) The absence of any of the required organ and tissue procurement procedures at any facility shall be noted by the division, and included in a written audit report or site review summary. In the event that an audit or facility review is conducted in conjunction with review by a national accreditation agency, and that agency prepares a report, the department shall request that the information required by this section with respect to organ and tissue procurement procedures be included in the report prepared by the national accreditation agency. In this event, the department shall not be required to prepare a separate report.