Form Rfa 802 - Compliant Intake Report
Download a blank fillable Form Rfa 802 - Compliant Intake Report in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Rfa 802 - Compliant Intake Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF SOCIAL SERVICES
COMPLAINT INTAKE REPORT
This form is intended to document complaints received in a county or CDSS office regarding a
Resource Family. Unless the complaint is considered harassment, a complaint visit must be
conducted within 10 calendar days after receipt of the complaint.
REPORT
REPORTED
COUNTY
COMPLAINT ID NUMBER
I
I
I
IN PERSON
BY LETTER/EMAIL
BY TELEPHONE
COMPLAINANT NAME
RESOURCE FAMILY INFORMATION
ADDRESS
STREET
RF NAME
CITY
ZIP CODE
RF ID FILE
TELEPHONE NUMBER (DAY)
TELEPHONE NUMBER (EVENING)
ADDRESS
STREET
(
)
(
)
AREA CODE
AREA CODE
RELATIONSHIP TO RESOURCE FAMILY
CITY
ZIP CODE
TELEPHONE NUMBER
I
I
I
WAS ABUSE REPORT REQUIRED AND FILED?
YES
NO
N/A
(
)
AREA CODE
I
I
DOES COMPLAINANT WISH TO REMAIN ANONYMOUS?
YES
NO
INSTRUCTIONS
1. Separate complaint into specific allegations numerically.
3. County must report all serious complaints to CDSS by close of next business
2. Describe all complaints received in county complaint log.
day after receipt of complaint.
4. County must notify CDSS upon completion of serious complaint investigation if
it intends to develop a Corrective Action Plan (CAP) and the final disposition of
the investigation.
RESOLUTION CODE*
ALLEGATION(S)
ALLEGATIONS
S
I
U
No.
* Resolution Code Key
Substantiated / S = means that the investigation concluded that based on a preponderance of evidence, meaning that it is more likely than not,
the allegation in a complaint occurred.
Inconclusive / I = means that the investigation concluded that the allegation in a complaint is not substantiated or unfounded.
Unfounded / U = means that the investigation concluded that the allegation in the complaint is false, meaning that there is no credible evidence
that the allegation in the complaint occurred.
COMPLAINT RECEIVED BY (PRINT NAME)
DATE COMPLAINT RECEIVED
TIME
VISIT DUE DATE
RFA 802 (9/16) MANDATORY (CONFIDENTIAL/PUBLIC DEPENDING ON TYPE OF INFORMATION)
PAGE 1 OF 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal