LIC 624 - Unusual Incident/Injury Report Author: CA Dept. of Social Services Subject: LIC 624 Form Created Date: 19990610132417Z
community care licensing division . death report . licensee must report the death of a client of any cause, regardless of where the death occurred. instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. submit written report within 7 days of occurrence. retain copy of report in client’s ...
LIC 624, Unusual Incident/Injury Report | California Childcare …
LIC 624, Unusual Incident/Injury Report (PDF; 78.21 KB) LIC 624 (SP), Reporte de incidente inusual o lesión (pdf; 80.58 KB) Updated November 2022, UCSF California Childcare Health Program. Print this page. Related Resources. Child Care Resources: Recovery from the Los Angeles Wildfires.
Unusual Incident or Injury reports must be submitted to your Licensing Analyst. Death Reports must be submitted by fax to the Complaints and Counselor Certification Division at (916) 440-5094 or by email to: [email protected].
1. Enter the facility number as shown on the license 2. Enter the licensee’s name as shown on license. 3. Enter the name of the facility as shown on the license. 4. Enter the number and street address, city, and zip code. 5. Enter the first and last name of …
Incident Report LIC 624 Form – Fill Out and Use This PDF
The Incident Report LIC 624 form is a crucial document used by the California Department of Social Services Community Care Licensing Division. It is designed for reporting unusual incidents or injuries that occur within licensed care facilities, detailing steps taken immediately after the incident and specifying follow-up actions.
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Form LIC624 - Fill Out, Sign Online and Download Fillable PDF ...
Form LIC 624, Unusual Incident/Injury Report, is an document created for daycare providers that allows them to report unusual incidents and/or injuries to the appropriate California state agencies. Alternate Names: LIC Injury Report Form; LIC Unusual Incident Report Form.
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Author: CA Dept. of Social Services Created Date: 06/10/2024 11:50:00 Title: LIC 624 - Unusual Incident/Injury Report Subject: LIC 624 Form Last modified by
LIC 624 - Unusual Incident/Injury Report Author: CA Dept. of Social Services Created Date: 4/20/2021 3:48:03 PM
COMMUNITY CARE LICENSING . PHYSICIAN’S REPORT FOR COMMUNITY CARE FACILITIES . For Resident/Client Of, Or Applicants For Admission To, Community Care Facilities (CCF). NOTE TO PHYSICIAN: The person specified below is a resident/client of or an applicant for admission to a licensed Community Care Facility. These
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