Form Lic 9216 - Complaint And Type A Violation Log
Download a blank fillable Form Lic 9216 - Complaint And Type A Violation Log 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 Lic 9216 - Complaint And Type A Violation Log 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
1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMPLAINT AND TYPE A VIOLATION LOG
Record any Substantiated (S) or Unsubstantiated (US) complaints of sexual or physical abuse and any other complaints relevant to the legal action.
G
Record all Type A Violations cited.
G
Record any resulting Informal Meeting (IM), Noncompliance Conference (NC), Compliance Conference (CC),
G
or Statement of Facts for Administrative Action (AA).
Citation Date,
Visit Type:
Description of Violation
Any Action
Complaint
Finding:
or Date of Finding
Complaint = C
Date Action
Include Regulation Title and Regulation Number
Taken?
Code from
Substantiated = S
if an Inconclusive
Annual = A
Taken
(Use separate lines if more than one on same date)
(IM, NC, CC, AA)
LIC 802
Unsubstantiated = US
Type A Allegation
Case Management = CM
LIC 9216 (3/17) - CONFIDENTIAL
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal