Form Lic 421cc - Civil Penalty Assessment - Child Care

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STATE OF CALIFORNIA ­ HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CIVIL PENALTY ASSESSMENT – 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 for which an  
DATE
immediate civil penalty is prescribed by California Health and Safety Code. See back of this form for further explanation.
$100 immediate civil penalty per parent or authorized representative for failure to provide, or obtain signature
indicating receipt of, the “Family Child Care Home (FCCH) Addendum to Notification of Parents’ Rights” regarding
“Removal/Exclusion” or “Reinstatement”.
0.00
Regarding Removal/Exclusion:
# of parents/authorized representatives: _____x $100 = $____________ penalty 
0.00
Regarding Reinstatement:
# of parents/authorized representatives: _____x $100 = $____________ penalty
$100 immediate civil penalty for failure to provide signed addendum to the Department when requested.
$100 immediate civil penalty for failure to comply with posting requirements for 30 consecutive days.
$50 immediate civil penalty for failure to return “Confirmation of Removal” form to Licensing within five days of form
date. (FCCH only)
$50 immediate civil penalty per violation of a second or subsequent denial of a parent or legal guardian to enter and
inspect a facility.
$50 immediate civil penalty per violation of a second or subsequent incident of retaliating against a child, parent, or
legal guardian for exercising the right to inspect a facility, or for lodging a complaint against a facility.
Total Penalty:  $___________
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 421CC (8/17)
PAGE 1 OF 2

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