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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?
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 Status ; LIC 9212 (10/05) - Consumer Awareness Information - Family ...
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 ...
state of california - health and human services agency california department of social services . physician's report for residential care facilities for the elderly (rcfe) i. facility information (to be completed by the licensee/designee) 1. name of facility 2. telephone ( ) 3. address . city . zip code . 4. licensee’s name . 5. telephone ( ) 6.
23 mar 2021 · Submitting notification with an attached death certificate using one of the Notice of Death forms below satisfies these reporting requirements under State law. Please complete the appropriate form with the most current information, review it for accuracy and submit them only once.
This form obligates the responsible entities to report the demise of a client to relevant authorities and entities by the next working day, followed by a detailed written report within seven days.
lic 602a (12/04) (confidential) page 1 of 6 1. name 2. birth date 3. age 6. tuberculosis (tb) test 1. signature of resident and/or resident's legal representative 4. licensee’s name 5. telephone ( ) 1. name of facility 2. telephone ( ) 6. facility license number 3. address city zip code 2. address 3. date a. date tb test given e.
