Form Lic 421d(Cc) - Civil Penalty Assessment - Death/serious Injury/physical Abuse (Child Care)

Download a blank fillable Form Lic 421d(Cc) - Civil Penalty Assessment - Death/serious Injury/physical Abuse (Child Care) in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Lic 421d(Cc) - Civil Penalty Assessment - Death/serious Injury/physical Abuse (Child Care) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CIVIL PENALTY ASSESSMENT – DEATH / SERIOUS INJURY / PHYSICAL ABUSE (CHILD CARE)
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 determined to
DATE
have resulted in the death or serious injury of a child, or that constitutes physical abuse of a child. A civil penalty is
prescribed by California Health and Safety Code Section 1596.99(e) or (f); or 1597.58(e) or (f).
Death
Penalty Amount
Capacity
Facility Type
I
30 or fewer
$7,500
I
31-100
Child Care Center
$10,000
I
101 or more
$15,000
I
All sizes
Small Family Child Care Home
$5,000
I
All sizes
Large Family Child Care Home
$7,500
Serious Injury / Physical Abuse
Penalty Amount
Capacity
Facility Type
I
30 or fewer
$2,500
Child Care Center
I
31-100
$5,000
I
101 or more
$10,000
I
All sizes
Small Family Child Care Home
$1,000
I
All sizes
Large Family Child Care Home
$2,000
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(CC) (6/17)
PAGE 1 OF 2

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Lic 421d(crp) - Civil Penalty Assessment - Death/serious Bodily Injury/physical Abuse (crp) Form Lic 421d(crp) - Civil Penalty Assessment - Death/serious Bodily Injury/physical Abuse (crp) Legal
Form Lic 421d(asc) - Civil Penalty Assessment - Death/serious Bodily Injury/physical Abuse (asc) Form Lic 421d(asc) - Civil Penalty Assessment - Death/serious Bodily Injury/physical Abuse (asc) Legal
Form Lic 421cc - Civil Penalty Assessment - Child Care Form Lic 421cc - Civil Penalty Assessment - Child Care Legal
Form Lic 421im - Civil Penalty Assessment - Immediate 500 Dollars And Repeat Violations Form Lic 421im - Civil Penalty Assessment - Immediate 500 Dollars And Repeat Violations Legal
Form Lic 421fc - Civil Penalty Assessment - Failure To Correct And Repeat Violations Form Lic 421fc - Civil Penalty Assessment - Failure To Correct And Repeat Violations Legal
Form Lic 421bg - Civil Penalty Assessment - Caregiver Background Check Form Lic 421bg - Civil Penalty Assessment - Caregiver Background Check Legal
Civil Penalty Assessment - State Of California - Health And Human Services Agency Civil Penalty Assessment - State Of California - Health And Human Services Agency Legal
Form Dphhs-qad/ccl-20a - Release Of Information For Registered And Licensed Child Care Providers Criminal Form Dphhs-qad/ccl-20a - Release Of Information For Registered And Licensed Child Care Providers Criminal Legal
Form Dhs-5914-eng - Death Or Serious Injury Report Fax Transmission Cover Sheet Form Dhs-5914-eng - Death Or Serious Injury Report Fax Transmission Cover Sheet Legal
Form Cc 12 - Child Care Assistance Program - Child Care Provider Rates And Responsibilities Form Form Cc 12 - Child Care Assistance Program - Child Care Provider Rates And Responsibilities Form Legal

Related Categories

Parent category: Legal
Download
Go
Page of 2