STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
DESCRIPTION OF INCIDENT. INCLUDE NATURE OF INCIDENT, ACTION TAKEN BY STAFF IN RESPONSE TO THE
INCIDENT, AND DISPOSITION OR CURRENT STATUS OF THE INCIDENT. FOR INCIDENTS IN GROUP HOMES,
INCLUDE A DESCRIPTION OF THE EVENTS LEADING UP TO THE INCIDENT.
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(Attach additional sheets as needed)
WAS MEDICAL TREATMENT REQUIRED FOR CLIENT?
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YES
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NO
IF YES, LIST NAME OF ATTENDING PHYSICIAN, FINDINGS, AND TREATMENT, IF ANY.
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MANUAL RESTRAINTS (GROUP HOMES / RUNAWAY AND HOMELESS YOUTH SHELTERS/ COMMUNITY TREATMENT
FACILITIES ONLY): DOES THE INCIDENT INVOLVE THE USE OF MANUAL RESTRAINTS?
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YES
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NO
IF YES, ATTACH A SEPARATE SHEET REPORTING INFORMATION REQUIRED BY SECTION 84061(h)(6) OF TITLE 22
REGULATIONS.
RUNAWAYS (GROUP HOMES/COMMUNITY TREATMENT FACILITIES ONLY): DOES THE INCIDENT INVOLVE A
RUNAWAY SITUATION?
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YES
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NO IF YES, ATTACH A SEPARATE SHEET REPORTING INFORMATION REQUIRED
BY SECTION 84061(h)(7) OF TITLE 22 REGULATIONS.
NAME/TITLE
DATE
Prepared by:
NAME/TITLE
DATE
Reviewed/Approved by:
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LIC 624-LE (4/17)