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LICENSEE MUST REPORT THE DEATH OF A CLIENT OF ANY CAUSE, REGARDLESS OF WHERE THE DEATH OCCURRED. INSTRUCTIONS : NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND RESPONSIBLE PERSONS, IF ANY, BY NEXT WORKING DAY. SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE. RETAIN COPY OF REPORT IN CLIENT’S FILE. MEDICAL TREATMENT NECESSARY?
To submit the California Death Report, complete the form accurately and retain a copy for your records. Send the completed form to the California Department of Social Services via fax at (###) ###-#### or email it to [email@example.com].
death report licensee must report the death of a client of any cause, regardless of where the death occurred. instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. submit written report within 7 days of occurrence. retain copy of report in client’s file. name of facility facility file ...
LIC 9182 (11/23) - Criminal Background Clearance Transfer Request ; LIC 9186 (2/01) - Client Death Report ; LIC 9187 (7/00) - Child Care Client Death Report ; LIC 9188 (11/23) - Criminal Record Exemption Transfer Request ; LIC 9200 (9/11) - Pre-Licensing Facility Evaluation Checklist ; LIC 9211 (9/21) - Request For Inactive Child Care License ...
Fill out and download the LIC624A Death Report form in California. Create a PDF version or fill it out online and save as a ready-to-print PDF. Completely free to use.
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