Form Lic 421fc - Civil Penalty Assessment - Failure To Correct And Repeat Violations
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1
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CIVIL PENALTY ASSESSMENT – FAILURE TO CORRECT AND REPEAT VIOLATIONS
FACILITY NAME
DATE
FACILITY ADDRESS
FACILITY #
CITY
STATE
ZIP CODE
LICENSEE(S)
A Licensing Report (LIC 809 or LIC 9099) was issued on ______________, giving notice of a violation for which a civil
DATE
penalty is prescribed by California Health and Safety Code Section 1548(b), 1568.0822(b), 1569.49(b), 1596.99(b), or 1597.58(b).
FAILURE TO CORRECT
The Licensing Report gave notice that failure to correct the violation below within a specified length of time would result in
a civil penalty. Because you failed to make the correction by the date specified, a civil penalty of $100 per violation per
day shall be assessed until the violation is corrected.
I
I
For a violation of:
California Code of Regulations
Health and Safety Code
CITATION
I
Interim Licensing Standard
I
A civil penalty of $100 per day is hereby assessed for the period of __________ through __________ .
DATE
DATE
I
The penalty assessed above is a continuation of a daily penalty that was first assessed on __________ .
DATE
Number of days: __________ x $100 per day = $ __________ total
0.00
REPEAT VIOLATION
I
I
For a violation of:
California Code of Regulations
Health and Safety Code
CITATION
I
Interim Licensing Standard
A previous licensing report was issued on ___________ giving notice of the same violation. Because you have been
DATE
cited for repeating the same violation within 12 months, the following civil penalty shall be assessed until the violation
is corrected.
I
An immediate civil penalty of $250 is hereby assessed for the day of __________ .
DATE
I
A civil penalty of $100 per day is hereby assessed for the period of __________ through ___________ .
DATE
DATE
This penalty is a continuation of a daily penalty that was first assessed on ___________ .
DATE
Number of days: __________ x $ __________ per day = $ __________ total
0.00
DO NOT SEND PAYMENT UNTIL YOU RECEIVE AN INVOICE.
NAME OF LICENSING PROGRAM ANALYST
SIGNATURE OF LICENSING PROGRAM ANALYST
DATE
DATE
NAME OF FACILITY REPRESENTATIVE/TITLE
SIGNATURE OF FACILITY REPRESENTATIVE
NAME OF SUPERVISOR/TITLE (FOR INTERNAL USE ONLY)
SIGNATURE OF SUPERVISOR
DATE
LIC 421FC (7/17)
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