Form Lic 812 - Detail Supportive Information
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1STATE OF CALIFORNIA
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
DETAIL SUPPORTIVE INFORMATION
Type of Activity:
This form is intended to document information that is relevant to the licensing file but generally not public information, such as collateral visits.
This would include back-up information on deficiencies such as conditions contributing to the severity of violations, witnesses to the
violations, or other observation from field notes. When used to support the Licensing Report (LIC 809) the form should be completed,
signed and dated shortly after the visit. This assures accuracy and completeness of the detail of the public report.
Public
Confidential
DATE(S) OF CONTACT
FACILITY NAME
FACILITY NUMBER
COLLATERAL VISIT
YES
NO
LICENSE EVALUATOR SIGNATURE
LICENSE EVALUATOR NAME (PRINT)
DATE
LIC 812 (8/06) (PERSONAL/CONFIDENTIAL DEPENDING ON TYPE OF INFORMATION
PAGE____ OF____ PAGES
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Parent category: Legal