Form Lic 624-Le - Law Enforcement Contact Report Page 3
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4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PART 2
NAME OF FACILITY (as appears on license)
DATE OF INCIDENT
DATE OF FOLLOW-UP
I
I
WAS ANY CHILD RESIDING IN THE FACILITY ALLEGED TO HAVE COMMITTED A CRIME:
YES
NO
LIST ANY CHILD INVOLVED (WHETHER OR NOT ALLEGED TO HAVE COMMITTED A CRIME), INCLUDE
CHILD(REN) FROM ORIGINAL INCIDENT (PART 1):
NAME
GENDER
RACE*
ETHNICITY*
AGE
Choose One
Other
Unknown
_________________________________________________________________________________________________
Unknown
Choose One
Other
_________________________________________________________________________________________________
Unknown
Choose One
Other
_________________________________________________________________________________________________
Other
Unknown
Choose One
_________________________________________________________________________________________________
*See last page for instructions on Race/Ethnicity
(Continue listing on separate sheet if necessary.)
LIST ANY STAFF INVOLVED:
NAME
POSITION
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
(If no staff were involved, enter “N/A” above.)
(Continue listing on separate sheet if necessary.)
WHO INITIATED CONTACT WITH LAW ENFORCEMENT? (Optional :
I
I
I
I
I
STAFF
OTHER YOUTH
NEIGHBOR
OTHER ___________________
UNKNOWN
TYPE OF OUTCOME
(check all that apply)
I
I
I
I
5150
Counselled by Law Enforcement
Mental Health Evaluation
Unknown
I
I
I
I
Arrest(s) Made
Juvenile Hall
Other _______________
Staff Disciplined
I
I
I
Child Removed
Detained by Law Enforcement
Returned to Facility
from Placement
(If any boxes above are checked, explain briefly here and include any additional information. Attach additional sheets as needed.)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
NAME/TITLE
DATE
Prepared by:
NAME/TITLE
DATE
Reviewed/Approved by:
PAGE 3 OF 4
LIC 624-LE (4/17)
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