Civil Penalty Assessment - State Of California - Health And Human Services Agency
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CIVIL PENALTY ASSESSMENT
FACILITY NAME
DATE
FACILITY ADDRESS
CITY
STATE
ZIP CODE
LICENSEE(S)/OPERATOR
FACILITY #:
LICENSED FACILITY
Civil penalties can be assessed against any facility which fails to take corrective action within prescribed time periods, per
California Health and Safety Code Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.58. You are hereby notified that a civil
penalty has been assessed.
The above facility has been found in violation of the California Code of Regulations, Title 22, Divisions 6, and/or 12,
Section(s) ______________________________________________________________________________________________
and/or California Health and Safety Code, Division 2, Chapters 3, 3.01, 3.2, 3.4, and 3.5, and 3.6.
Section(s) ______________________________________________________________________________________________
A Licensing Report (LIC 809 or LIC 9099) was issued on _______________________________ giving notice that failure to
DATE
correct the above violation(s) would result in a civil penalty.
I
Because you failed to make the corrections specified on the LIC 809, a civil penalty of $____________ is assessed for the
period from ________________ through ________________.
DATE
DATE
I
A civil penalty of $50 per violation per day, up to a maximum of $150 per violation per day will be assessed. This will
continue until correction(s) is made to comply with the licensing laws, regulations, and approval of the California
Department of Social Services or authorized licensing agency.
I
Because you repeated a violation of the same subsection within a 12-month period, an immediate civil penalty of
$__________ is assessed for the period from __________________ through __________________.
DATE
DATE
I
All Facility Types Except Child Care Centers: Second citation within a 12 month period; an immediate civil penalty of
$150 per violation; then $50 per day per violation until corrections are made.
I
Child Care Centers Only: Second citation within a 12-month period; an immediate civil penalty of $150 per violation;
then $150 per day per violation until corrections are made.
I
Residential Care Facility for the Elderly (RCFE), Residential Care Facility for the Chronically Ill (RCF-CI): Third citation
within a 12-month period; an immediate civil penalty of $1,000 per violation; then $100 per day per violation until
corrections are made.
I
Family Child Care Home (FCCH), Child Care Center (CCC), Community Care Facility (CCF): Third citation within 12-
month period; an immediate civil penalty of $150 per violation; then $150 per day per violation until corrections are made.
I
FCCH and CCC only: Second or subsequent violation for failure to allow parent or guardian to enter and inspect facility
or for retaliation/discrimination stemming from a request to enter or lodge a complaint. A civil penalty of $50 per violation.
Total Penalty Assessed $____________________
YOU WILL RECEIVE AN INVOICE IN THE MAIL.
DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE
NAME OF LICENSING PROGRAM ANALYST
NAME OF FACILITY REPRESENTATIVE/TITLE
SIGNATURE OF LICENSING PROGRAM ANALYST
SIGNATURE OF FACILITY REPRESENTATIVE
SUPERVISOR REVIEW/SIGNATURE (FOR INTERNAL USE ONLY)
DATE
TITLE
LIC 421 (12/15)
PAGE 1 OF 2
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