STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CIVIL PENALTY ASSESSMENT – DEATH / SERIOUS BODILY INJURY / PHYSICAL ABUSE (CRP)
FACILITY
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 determined to
DATE
have resulted in the death or serious bodily injury of a child, or that constitutes physical abuse of a child. A civil penalty is
prescribed by California Health and Safety Code Section 1548(e) or (f).
Death
Penalty Amount
Capacity
Facility Type
I
All sizes
Adoption Agency, Foster Family Agency
$7,500
I
40 or fewer
Community Treatment Facility, Group Home, Enhanced Behavioral Supports
$7,500
Home (licensed as a Group Home), Transitional Housing Placement Provider,
I
41-100
$10,000
Short-Term Residential Therapeutic Program, Transitional Shelter Care Facility,
Small Family Home, Crisis Nursery
I
101 or more
$15,000
I
All sizes
Runaway and Homeless Youth Shelter (licensed as a Group Home)
$5,000
Serious Bodily Injury / Physical Abuse
Penalty Amount
Capacity
Facility Type
I
All sizes
Adoption Agency, Foster Family Agency
$2,500
I
40 or fewer
Community Treatment Facility, Group Home, Enhanced Behavioral Supports
$2,500
Home (licensed as a Group Home), Transitional Housing Placement Provider,
I
41-100
$5,000
Short-Term Residential Therapeutic Program, Transitional Shelter Care Facility,
Small Family Home, Crisis Nursery
I
101 or more
$10,000
I
All sizes
Runaway and Homeless Youth Shelter (licensed as a Group Home)
$1,000
A civil penalty of $_______________ is hereby assessed.
DO NOT SEND PAYMENT UNTIL YOU RECEIVE AN INVOICE
NAME OF PROGRAM ADMINISTRATOR
SIGNATURE OF PROGRAM ADMINISTRATOR
DATE
DATE
NAME OF LICENSING PROGRAM ANALYST
SIGNATURE OF LICENSING PROGRAM ANALYST
NAME OF FACILITY REPRESENTATIVE/TITLE
SIGNATURE OF FACILITY REPRESENTATIVE
DATE
LIC 421D(CRP) (6/17)
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