Form Lic 9099 - Complaint Investigation Report

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
COMPLAINT INVESTIGATION REPORT
COMPLAINT CONTROL NUMBER __________________
This is an official report of an unannounced visit/investigation of a complaint received in our office on_____________________and
conducted by Evaluator _________________________________________________________
FACILITY NAME
FACILITY NO.
FACILITY TYPE
FACILITY REPRESENTATIVE
ADDRESS
TELEPHONE
CAPACITY
CENSUS
MET WITH
TIME IN
TODAY'S DATE
I
I
PUBLIC
CONFIDENTIAL
ALLEGATION(S):
INVESTIGATION FINDINGS:
Needs Further Investigation
I
I
I
I
Substantiated
Unsubstantiated
Unfounded
Estimated Days of Completion _____________________
USE LIC 809 FOR ALL CITATIONS
LICENSING ANALYST SIGNATURE
TIME OUT
TELEPHONE
I acknowledge receipt of this form and understand my
(
)
appeal rights as explained on the back of this form.
NAME OF SUPERVISOR
TELEPHONE
SIGNATURE
DATE
(
)
Distribution: Original: Agency
Duplicate: Facility
Page 1 of ______
LIC 9099 (12/16)

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