STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CIVIL PENALTY ASSESSMENT – DEATH / SERIOUS BODILY INJURY / PHYSICAL ABUSE (ASC)
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 bodily injury of a client, or that constitutes physical abuse of a client. A civil penalty
is prescribed by California Health and Safety Code Section 1548(e) or (f); 1568.0822(e) or (f); or 1569.49(e) or (f).
Death
Penalty Amount
Capacity
Facility Type
Adult Residential Facility, Enhanced Behavioral Supports Home (licensed as an
I
All sizes
Adult Residential Facility), Social Rehabilitation Facility, Adult Residential
$15,000
Facility for Persons With Special Health Care Needs, Community Crisis Home
I
50 or fewer
$7,500
Adult Day Program
I
51 or more
$10,000
I
All sizes
Residential Care Facility for the Chronically Ill
$15,000
I
All sizes
Residential Care Facility for the Elderly
$15,000
Serious Bodily Injury / Physical Abuse
Penalty Amount
Capacity
Facility Type
Adult Residential Facility, Enhanced Behavioral Supports Home (licensed as an
I
All sizes
Adult Residential Facility), Social Rehabilitation Facility, Adult Residential
$10,000
Facility for Persons With Special Health Care Needs, Community Crisis Home
I
50 or fewer
$2,500
Adult Day Program
I
51 or more
$5,000
I
All sizes
Residential Care Facility for the Chronically Ill
$10,000
I
All sizes
Residential Care Facility for the Elderly
$10,000
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(ASC) (6/17)
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