Form Lic 989a - Non-Confidential Records Request Form
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
NON-CONFIDENTIAL RECORDS REQUEST FORM
(A person requesting non-confidential files, records and residential or care facility
information maintained by the Department of Social Services, Community Care
DATE
Licensing Division is required to date and fill out sections 1, 2 and 3 of this form.)
SECTION 1
NAME (PLEASE PRINT)
STREET (P.O. BOX)
CITY
STATE
ZIP CODE
SIGNATURE
TELEPHONE NUMBER
(
)
SECTION 2
FACILITY NAME/FACILITY LICENSE NUMBER
LICENSEE’S NAME, IF KNOWN
ADDRESS
CITY
STATE
SECTION 3
INFORMATION REQUESTED
OFFICE USE ONLY
Request has been:
Approved
Denied
REASON(S) FOR DENIAL:
SIGNATURE (LICENSING PROGRAM MANAGER OR DESIGNEE)
DATE
LIC 989A (3/17) (NON-CONFIDENTIAL RECORDS REQUEST FORM)
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