Civil Penalty Assessment - State Of California - Health And Human Services Agency Page 2
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
INSTRUCTIONS FOR COMPLETING THE
CIVIL PENALTY ASSESSMENT FORM FOR LICENSED FACILITIES
EXPLANATION TO LICENSEE
A visit was conducted at the above facility by a Licensing Evaluator. During that visit one or more violations of licensing
statutes and regulations were identified. A Facility Evaluation Report (LIC 809) was issued establishing the dates by
which corrections must have been made.
Since you have failed to make all of the required corrections, you must pay the civil penalty described on the front of this
form until you have confirmed to the satisfaction of the California Department of Social Services that each of the violations
has been corrected.
IT IS YOUR RESPONSIBILITY to notify the licensing agency in writing or by the telephone when the required corrections
have been made.
Payment is due when billed and the check(s) shall be made payable to the "California Department of Social Services".
Please write the facility number and invoice number on your check. DO NOT SEND CASH.
NOTE: Civil penalties may be imposed in addition to the penalties of suspension or revocation as provided in the
California Health and Safety Code Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.58. In addition to the
imposition of civil penalties, the California Health and Safety Code Sections 1550, 1569.50 and 1596.885 also authorizes
the suspension or revocation of a license based on licensing violations.
APPEAL RIGHTS
The licensee has a right without prejudice to discuss any disagreement concerning the proper application of licensing laws and
regulations with the licensing agency. The licensee may request a formal administrative review of any civil penalty or notice of
deficiency, to be conducted by the Regional Manager, following the timelines listed below:
•
Within 15 business days of receipt of this form, the licensee may request a formal review of any civil penalty or notice of
deficiency. The request must be in writing and should be sent to the Regional Office of jurisdiction over the facility. The
licensee must include all available supporting documentation with the request for review.
•
Within 30 business days of the request for review, the licensee may submit additional supporting documentation that was
unavailable at the time of the initial request.
•
Within 30 business days of receiving the initial request from the licensee, the licensing agency may request additional
information from the licensee deemed necessary to make its determination.
•
Within 30 business days of receiving the licensing agency’s request for additional information, the licensee shall provide
this additional information.
•
Within 60 business days of the date when all necessary information has been provided to the department by the licensee,
the licensee shall be notified in writing of the licensing agency’s decision.
The licensing agency has a duty to review the facts presented without prejudice. Upon review of the facts and in accordance with
applicable statutes or regulations, the licensing agency may amend any portion of the action taken or may dismiss the violation.
Within 15 business days of receiving the Regional Manager’s decision, the licensee may further appeal the decision to the
Program Administrator. The same timelines as above applies. The Program Administrator’s decision is considered final and
concludes the licensee’s administrative appeal rights.
LIC 421 (12/15)
PAGE 2 OF 2
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