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 ...
HOW, WHAT AND WHEN TO REPORT: Affected facilities may(but are not required to) use the LIC 624-LE to report incidents under the law. If a facility uses another method to report an incident, that method must capture all of the information specified by Health and Safety Code section 1538.7(a), and must be submitted within the time allowed by the law.
LIC 624, Unusual Incident/Injury Report | California ...
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
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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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].
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