Form Rfa 9099c - Compliant Investigation Report - Continued

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
County:
FOR COUNTY USE ONLY
Address/Contact Information:
Amended: _____________________
(Date Of Original Report)
Complaint ID Number:
COMPLAINT INVESTIGATION REPORT - CONTINUED
Purpose of Form: Use this form to document all substantiated allegations that require a Corrective Action Plan (CAP).
It is the intent of the RFA worker to conduct all interactions and communications with the Resource Family with courtesy and respect and to be
minimally disruptive to the Resource Family and the children in their care while also ensuring that the home is a safe and nurturing placement.
Resource Family Name:
Resource Family ID Number:
DESCRIBE HOW THE
DUE DATE
DESCRIBE EACH DEFICIENCY
DEFICIENCY WILL BE CORRECTED
I acknowledge receipt of this report and understand my appeal rights as explained on the following page of this form.*
RF PRINTED NAME:
RF SIGNATURE:
DATE:
TELEPHONE NUMBER:
RF WORKER PRINTED NAME:
RF WORKER SIGNATURE:
DATE:
TELEPHONE NUMBER:
RF WORKER SUPERVISOR PRINTED NAME:
TELEPHONE NUMBER:
RFA 9099C (9/17) (Mandatory)
(Confidential/Public Depending on Type of Information)
Distribution: Original: County
Copy: Resource Family
Page ____ of _____
_

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