Form Lic 421bg - Civil Penalty Assessment - Caregiver Background Check
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1
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CIVIL PENALTY ASSESSMENT – CAREGIVER BACKGROUND CHECK
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 1522, 1568.09, 1569.17, or 1596.871.
A civil penalty of $100 per person per day is hereby assessed.
The individuals below were found to have been working, residing or volunteering at the facility:
• Without a criminal record clearance or exemption. Violation Code: CRC
• Without a clearance transfer or exemption transfer. Violation Code: CT
• When that person is subject to an Order of Removal. Violation Code: OR
# of Days in
Daily
Individual in Violation
Violation Code
X
=
Penalty
Violation
Penalty
100
1
X
= $
0.00
100
2
X
= $
0.00
100
3
X
= $
0.00
100
4
X
= $
0.00
100
5
X
= $
0.00
100
6
X
= $
0.00
100
7
X
= $
0.00
100
8
X
= $
0.00
100
9
X
= $
0.00
100
10
X
= $
0.00
0.00
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 421BG (6/17)
PAGE 1 OF 2
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