Form Lic 9029a - Statement Of Facts Summary Sheet
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9STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF FACTS SUMMARY SHEET
A. To Be Completed by Program Office:
Legal Case #:
Program:___
Appeal Rec’d:
Acknowledgment Letter Sent:
SOF Due:
B. To Be Completed by R.O./County
FACILITY #:
CAPACITY:
OPERATING?
FACILITY TYPE (Choose 1)
YES
/
NO
■
■
Decertified or
Last, First MI
Phone
400 AA
740 RCFE
■
■
Excluded
430 FFA
772 SRF
■
■
Individual
431FFAsub
775 ADP
(
)
■
■
433 CFFH
810 FCCH
■
■
710 SFH
830 CCC-INF
Address
#/Street/City
Zip
■
■
711 FFH
840 CCC-SA
■
■
720 CN
845 CCC-III
■
■
726 THPP
850 CCC
Cert Fam.
Phone
■
■
728 CTF
900 TLR
Home
■
730 GH
(
)
■
734 ARFPSHN
Address
#/Street/City
Zip
■
735 ARF
■
736 RCFCI
Licensee
Phone
Telephone
Attorney Name:
Name
TSO
(
)
Address
#/Street/City
Zip
Date Program Administrator/Assistant
Program Administrator Approved:
Facility
Phone
Immediate
Date Served:
Name
Exclusion
(
)
/
/
Address
Zip
Attorney
Name:
Consulted
Date First Licensed/Certified:
# of other facilities:
Attach additional summary sheets
■
■
CFFH - Date decertified:
Capacity:
Current census:
Dual Licensure
Yes
No
VIOLATIONS (Choose all that pertain)
TYPE OF ACTION REQUESTED
15 NonImmed Exc -
01 Physical Abuse
11 Food Service
01 Denied Application
Admin
16 NonImmed Exc -
02 Sexual Abuse
12 False Statements
02 Telephone TSO
Other
03 Other Persons
17 Denied Exemption
13 Medications
03 TSO
Rights/Restraints
Action
04 Unlicensed
14 Financial Abuse
04 Revocation
18 Admin Decert.
05 Fire Clearance
15 Level of Care
41 Expedited Revocation
06 Crimes - no arrest
16 Qualifications
05 Inj/TRO
61 Crimes-Conv Exemp
17 Financial Issues
06 Attorney Review
Denied
62 Crimes-Non Exemptible
18 Questionable Death
08 Revoke Prob
63 Crimes-Arrest Only
19 Other
09 FFA Certified Family Action
07 Physical Plant
21 Ritualistic Abuse
11 Immed. Exc-Employee
08 Record Keeping
22 Physical Punishment
12 Immed. Exc-Administration
09 License/Cap.
23 CAIC Match
13 Immed. Exc-Other
10 Neglect/Lack of Sup
24 Conduct Inimical
14 NonImmed Exc-Employee
25 Failure To Pay Initial
and/or Annual Fees
Page 1 of 9
LIC 9029A (1/08)
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Parent category: Legal