Lic 624 Death Report. The CA HHSA LIC 624 form is a crucial document for reporting

The CA HHSA LIC 624 form is a crucial document for reporting unusual incidents or injuries in community care settings. If reported by telephone, submit written report within 7 calendar days of the incident/injury to Licensing. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION DESCRIBE IMMEDIATE CAUSE OF DEATH (IF CORONER REPORT MADE, SEND COPY WITHIN 30 DAYS): DESCRIBE CONDITIONS PRIOR TO OR CONTRIBUTING TO DEATH: EXPLAIN WHAT IMMEDIATE ACTION WAS TAKEN (INCLUDE PERSONS CONTACTED): AGENCIES/INDIVIDUALS NOTIFIED (SPECIFY NAME AND DEATH REPORT LICENSEE MUST REPORT THE DEATH OF A CLIENT OF ANY CAUSE, REGARDLESS OF WHERE THE DEATH OCCURRED. 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. Save or instantly send your ready documents. Notify Licensing by telephone, fax, or e-mail before end of next working day. If reported to the Department by telephone, submit written report within 7 calendar days of the event. This form helps in reporting incidents, such as arrests, investigations, or any relevant information that may impact the safety and well-being of children in these settings. show details. The purpose of this form is to notify the licensing agency, placement agency, and responsible parties (if any) about the client's death. No need to install software, just go to DocHub, and sign up instantly and for free. During today's televisit, LPA briefly toured the facility, interviewed staff, and requested copies of C1's records and death certificate. Within the next business day, notify the Department by telephone or fax of the events listed in #11. The California Death Report form is a critical document required by the California Department of Social Services to report the death of a client in a licensed facility. [The report appears: form LIC 624B for family child care homes and LIC 624 for child care centers. acknowledge that by providing my electronic signature for this form, I agree my electronic signature is the legal binding equivalent to my handwritten signature. Download it as a PDF or fill it out digitally and save as a printable PDF. Complete Ca Death Report online with US Legal Forms. UNUSUAL INCIDENT/INJURY REPORT NAME OF FACILITY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION What reports am I required to submit to licensing? There are two types of reports. UNUSUAL INCIDENT/INJURY REPORT NAME OF FACILITY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION The LIC 624 LE, also known as the Law Enforcement Contact Report, is a form used to document any interactions or contact between law enforcement agencies and child care centers or family child care homes. The report should include the following: Name of the individual involved, if provided Date the individual was exposed to COVID-19 or confirmed positive Child’s age, sex, and date of admission Download Law Enforcement Contact Report (LIC 624-LE) – Department of Social Services (California) form DESCRIBA EL EVENTO O INCIDENTE (INCLUYA LA FECHA, HORA, SITIO, PERPETRADOR, ORIGEN DEL INCIDENTE, CUALQUIER ANTECEDENTE QUE LLEVO AL INCIDENTE Y COMO LOS CLIENTES FUERON AFECTADOS INCLUYENDO CUALQUIER LESION): PERSONAS QUE OBSERVARON EL INCIDENTE/LESION: EXPLIQUE QUE ACCION INMEDIATA SE TOMO (INCLUYA A LAS PERSONAS CONTACTADAS) : LIC 624 (SP Resident Appraisal of Needs Death Report LIC 601 - Identification and Emergency Information LIC 602A - Physician's Report for RCFE LIC 603 - Preplacement Appraisal Information LIC 604A - RCFE Guide to Admission Agreements LIC 605A - Release of Client Medical Information LIC 610D - Emergency Disaster Plan LIC 610E - Emergency and Disaster Plan . You must also complete the Unusual Incident Report (UIR) LIC 624 for centers or LIC 624b for family child care homes within one business day. Download Law Enforcement Contact Report (LIC 624-LE) – Department of Social Services (California) form Dec 1, 2022 · Download Fillable Form Lic624 Le In Pdf - The Latest Version Applicable For 2025. Apr 1, 2017 · Download Fillable Form Lic624-le In Pdf - The Latest Version Applicable For 2026. O. Try Now! LIC 198B (9/23) - Out-Of-State Child Abuse/Neglect Report Request LIC 200 (2/24) - Application For A Community Care Facility or Residential Care Facility For The Elderly License K. This report is crucial for beneficiaries to proceed with claims on the insured's policy, ensuring a timely payout. Easily complete the LIC624A Death Report form in California online for free. 7(a) of the Health and Safety Code, “A group home, transitional housing place ment provider, community treatment facility, runaway and homeless youth shelter, or short term residential therapeutic program shall report to the department’s Community Care Licensing Division upon the occurrence of any incident concerning a child in The CA LIC 624 is an essential document required to report the death of a client in a facility. [The host speaks as the corresponding content is displayed LIC 624B, Unusual Incident/Injury Report Family Child Care LIC 624B, Unusual Incident/Injury Report Family Child Care Home Updated November 2022, UCSF California Childcare Health Program. Suspected Cause of Death and Person Making that Determination: Enter suspected cause of client death as determined by law enforcement, physician, paramedic report, etc. LIC 624 Unusual Incident/Injury Report L. TODAY’S DATE FACILITY LICENSE NUMBER: usual incident/injury”. ] These reports are required of both family child care homes and centers. TODAY’S DATE FACILITY LICENSE NUMBER: Breadcrumb Home Resources Disaster Preparedness LIC 624, Unusual Incident/Injury Report Death Other (explain) DESCRIBE EVENT OR INCIDENT (INCLUDE DATE, TIME, LOCATION, PERPETRATOR, NATURE OF INCIDENT, ANY ANTECEDENTS LEADING UP TO INCIDENT AND HOW CLIENTS WERE AFFECTED, INCLUDING ANY INJURIES: PERSON(S) WHO OBSERVED THE INCIDENT: EXPLAIN WHAT IMMEDIATE ACTION WAS TAKEN (INCLUDE PERSONS CONTACTED): Complete CA LIC 624A 1999-2026 online with US Legal Forms. It mandates that licensees report any client death, regardless of location, to the licensing agency and responsible parties by the next working day, and submit a written report within seven days. The LIC 624 death report is a document issued by life insurance companies to provide evidence of a policyholder's death. Try Now! The Lic 624 form is an essential document for reporting unusual incidents or injuries in community care settings. LIC 622 Centrally Stored Medication and Destruction Record N. When an incident occurs, it’s imperative to notify relevant parties and complete this report within seven days to ensure proper follow-up and accountability. Keep a copy of the report in the child’s facility file. INSTRUCTIONS : NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND RESPONSIBLE PERSONS, IF ANY, BY NEXT WORKING DAY. submit written report within 7 days of Life insurance corporation, popularly known as lic is indian state-owned insurance group and investment company. The Incident Report LIC 624 form is a crucial document used by the California Department of Social Services Community Care Licensing Division. People Also Ask about unusual incident report lic 624 What is LIC 624? What is an unusual incident report? UNUSUAL INCIDENT/INJURY REPORT NAME OF FACILITY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION The Incident Report Lic 624 form serves as a crucial tool for documenting unusual incidents or injuries within care facilities in California. DESCRIBE EVENT OR INCIDENT (INCLUDE DATE, TIME, LOCATION, PERPETRATOR, NATURE OF INCIDENT, ANY ANTECEDENTS LEADING UP TO INCIDENT AND HOW CLIENTS WERE AFFECTED, INCLUDING ANY INJURIES: PERSON(S) WHO OBSERVED THE INCIDENT/INJURY: EXPLAIN WHAT IMMEDIATE ACTION WAS TAKEN (INCLUDE PERSONS CONTACTED): LIC 624 (4/99) The California Death Report form is a critical document required by the California Department of Social Services to report the death of a client in a licensed facility. Unusual Incident / Injury LIC 624 Madison House Email to your supervisor LIC 9269 (3/21) – Form 5-5: Annual Reserve Certification LIC 9270 (9/22) – Form 7-1: Report On CCRC Monthly Care Fees LIC 9271 (6/21) – Form 9-1: Calculation Of Refund Reserve Amount LIC 9272 (11/21) – Annual Report Checklist LIC 9273 (7/23) – Continuing Care Retirement Community Disclosure Statement LIC 9274 (11/21) – Key LIC 610, Emergency Disaster Plan for Child Care Centers LIC 610A, Emergency Disaster Plan for Family Child Care Homes LIC 624, Unusual Incident/Injury Report LIC 624A, Death Report LIC 624B, Unusual Incident/Injury Report — Family Child Care Home LIC 999, Facilities Sketch DESCRIBE IMMEDIATE CAUSE OF DEATH (IF CORONER REPORT MADE, SEND COPY WITHIN 30 DAYS): DESCRIBE CONDITIONS PRIOR TO OR CONTRIBUTING TO DEATH: UNUSUAL INCIDENT/INJURY REPORT NAME OF FACILITY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LIC 624A, Death Report English LIC 624A, Death Report (pdf; 54. 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. Edit, sign, and share lic 624 online. Jul 1, 2025 · The Department received an Unusual Incident Report LIC 624 on June 25, 2025, regarding an incident that occurred at 7:45 PM. Implementation of this guidance hereby authorize release of medical information in this report to the facility named above. [The host speaks as the corresponding content is displayed UNUSUAL INCIDENT/INJURY REPORT NAME OF FACILITY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION Sep 28, 2023 · The purpose of today's visit is to address a self reported Unusual Incident/Injury Report (LIC 624) reported to CCL on 09/17/2023. LIC 624-UNUSUAL INCIDENT/INJURY REPORT or LIC 624A-DEATH REPORT. One type is unusual incidents. Buy life insurance plans and policies from LIC of india avail tax benefits with multiple cover options. The LIC 624B form serves as an essential document for family child care homes in California, required by the California Department of Social Services. You must fill out the appropriate form (LIC 624 for centers, LIC 624B for Jun 23, 2023 · This report must be available at Child Care and Group Home facilities for public review for 3 years. It was reported that Resident #1 (R1) was able to elope from the community unsupervised. This guide provides step-by-step instructions on how to complete the form online, ensuring accuracy and compliance with state regulations. It is crucial to follow the proper procedures for accurate documentation. DESCRIBE IMMEDIATE CAUSE OF DEATH (IF CORONER REPORT MADE, SEND COPY WITHIN 30 DAYS): (j) The licensee shall submit reports to the Department, using form LIC 624-LE or a report containing all the information required in LIC 624-LE, regarding any incident that involves law enforcement contact with a participant residing in a THPP living unit. 1 KB) Updated December 2025 , UCSF California Childcare Health Program The document outlines the procedures for reporting the death of a client in a facility licensed by the California Department of Social Services. Fill Out The Law Enforcement Contact Report - California Online And Print It Out For Free. The LIC 624A Death Report is a mandatory form that licensees must complete and submit when a client dies, regardless of the cause and location of death. As of 1-99 there will be two reporting forms, the LIC 624, for incidents and injuries only, and the LIC 624A for deaths. The self reported Unusual Incident/Injury Report (LIC 624) pertains to an incident that occurred on 9/17/2023 regarding Resident #1 (R1) and two staff (S1, S2). Easily fill out PDF blank, edit, and sign them. LIC 610, Emergency Disaster Plan for Child Care Centers LIC 610A, Emergency Disaster Plan for Family Child Care Homes LIC 624, Unusual Incident/Injury Report LIC 624A, Death Report LIC 624B, Unusual Incident/Injury Report — Family Child Care Home LIC 999, Facilities Sketch DESCRIBE EVENT OR INCIDENT (INCLUDE DATE, TIME, LOCATION, PERPETRATOR, NATURE OF INCIDENT, ANY ANTECEDENTS LEADING UP TO INCIDENT AND HOW CLIENTS WERE AFFECTED, INCLUDING ANY INJURIES: PERSON(S) WHO OBSERVED THE INCIDENT/INJURY: EXPLAIN WHAT IMMEDIATE ACTION WAS TAKEN (INCLUDE PERSONS CONTACTED): LIC 624 (4/99) May 17, 2017 · ABOUT THE LIC 624 LE THE LAW: In accordance with section 1538. Jun 12, 2023 · Local health jurisdictions may continue to implement additional requirements that go beyond this statewide guidance based on local circumstances. Fill CA LIC 624 instantly, Edit online. SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE. Sign, fax and printable from PC, iPad, tablet or mobile. 469 California Legal Forms And Templates are collected for any of your needs. If an accidental switch DOES occur, must call the licensing agency by telephone by the next day to report the unusual incident and then submit the wri ten report within 7 days. How to fill out a CA HHSA 624 Form What is the CA HHSA 624 Form? The CA HHSA LIC 624 Form is a crucial document required by California's health and human services sector. lic 624 unusual incident report robert oppenheimer family April 14, 2023 how to find ilo ip address using powershell July 17, 2021 bulmaro garcia cause of death July 11, 2021 gloria pepin health July 4, 2021 noticias ya san diego promociones July 4, 2021 UNUSUAL INCIDENT/INJURY REPORT NAME OF FACILITY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION UNUSUAL INCIDENT/INJURY REPORT NAME OF FACILITY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LIC 610, Emergency Disaster Plan for Child Care Centers LIC 610A, Emergency Disaster Plan for Family Child Care Homes LIC 624, Unusual Incident/Injury Report LIC 624A, Death Report LIC 624B, Unusual Incident/Injury Report — Family Child Care Home LIC 999, Facilities Sketch usual incident/injury”. RETAIN COPY OF REPORT IN CLIENT’S FILE. Browse 609 California Department Of Social Services Forms And Templates collected for any of your needs. Its purpose is to report unusual incidents or injuries that occur within care facilities. UNUSUAL INCIDENT/INJURY REPORT NAME OF FACILITY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION DESCRIBE EVENT OR INCIDENT (INCLUDE DATE, TIME, LOCATION, PERPETRATOR, NATURE OF INCIDENT, ANY ANTECEDENTS LEADING UP TO INCIDENT AND HOW CLIENTS WERE AFFECTED, INCLUDING ANY INJURIES: PERSON(S) WHO OBSERVED THE INCIDENT/INJURY: EXPLAIN WHAT IMMEDIATE ACTION WAS TAKEN (INCLUDE PERSONS CONTACTED): LIC 624 (4/99) Within the next business day, notify the Department by telephone or fax of the events listed in #11. 7(a), and must be submitted within the time allowed by the law. The Licensee's authorized representative self-reported this incident by submitting Form LIC 624A - Death Report to Community Care Licensing (CCL), which was received by CCL on August 5, 2020. , include date and time. state of california - health and human services agency california department of social services community care licensing division unusual incident/injury report instructions notify licensing agency placement agency and responsible persons if any by next working day. LIC 624B, Unusual Incident/Injury Report — Family Child Care Home Updated December 2025 , UCSF California Childcare Health Program (i) The licensee shall submit reports to the Department, using form LIC 624-LE or a report containing all the information required in LIC 624-LE, regarding any incident that involves law enforcement contact with a child residing in the facility. LIC 624A Death Report M. What is the 624A form? The LIC 624A form, also known as the Death Report, is essential for reporting the death of clients in California's care facilities. Form Lic624-le Is Often Used In Contact Report, Law Enforcement Report, Law Enforcement, California Department Of Social Services, California Legal Forms And United States Legal Forms. On April 21, 2025, the Department received an LIC 624 Unusual Incident Report and an LIC 624A Death Report regarding an incident that occurred on April 9, 2025. You must fill out the appropriate form (LIC 624 for centers, LIC 624B for Sep 28, 2023 · The purpose of today's visit is to address a self reported Unusual Incident/Injury Report (LIC 624) reported to CCL on 09/17/2023. Download Death Report (LIC 624A) – Department of Social Services (California) form The California Death Report form, officially known as the LIC 624A, is a critical document required by the State of California's Health and Human Services Agency and overseen by the California Department of Social Services Community Care Licensing Division. Keep a copy of the report submitted to the Department in the (affected) child’s record. Simplify the process of reporting a death with our user-friendly platform. 6 hours ago get lic 624 get form. Previously incidents, injuries and deaths were reported on one form, the LIC 624. Report of unusual incident, event, serious injury requiring medical attention, or death, while the resident is under facility supervision, Unusual Incident/Injury/Report (LIC 624). 7(a) of the Health and Safety Code, “A group home, transitional housing place-ment provider, community treatment facility, runaway and homeless youth shelter, or short-term residential therapeutic program shall report to the department’s Community Care Licensing Division upon the occurrence of any incident concerning a child in LIC 624-UNUSUAL INCIDENT/INJURY REPORT or LIC 624A-DEATH REPORT. Timely notification to relevant agencies and careful completion of the form can ensure adherence to legal obligations and support transparency. This guide will provide you with clear instructions on how to complete the form accurately and efficiently online. Copy of removal and/or discharge procedures (developed by social work staff) which has been signed by child and authorized PIN 23-02-CRP - Revision of LIC 624-LE, Law Enforcement Contact Report PIN 23-01-CRP - 2022 Chaptered Legislation Affecting Children’s Residential Facilities and Homes: Summary and Implementation Download Unusual Incident/Injury Report (LIC 624) – Department of Social Services (California) form Death - There is reason to believe that the incident caused or hastened child’s death (Complete LIC 9187 Death Report Form) Apr 24, 2023 · We would like to show you a description here but the site won’t allow us. If there are differing requirements between the most current CDPH, Community Care Licensing (CCL), Cal/OSHA, and local health department guidance or health orders, providers should follow the strictest requirements. This guide provides clear instructions for completing the form online, ensuring that you meet the necessary reporting requirements efficiently. This form is used to report any unusual incidents or injuries involving children in care, ensuring that all necessary parties are notified and that measures are taken to prevent future occurrences. Evidence that child’s progress reports are given to Authorized Representative. How to fill out lic 624 unusual incident report form How to fill out a death incident report? 01 Jun 23, 2023 · This report must be available at Child Care and Group Home facilities for public review for 3 years. ABOUT THE LIC 624-LE THE LAW: In accordance with section 1538. Welcome to the Community Care Licensing Division We serve the most vulnerable people of California and our mission is to promote the health, safety, and quality of life of each person in community care through the administration of an effective and collaborative regulatory enforcement system. Form Lic624 Le Is Often Used In Contact Report, Law Enforcement, California Department Of Social Services, California Legal Forms, Legal And United States Legal Forms. HOW AND WHEN TO REPORT: Affected facilities may (but are not required to) use the LIC 624-LE to report incidents under the law. UNUSUAL INCIDENT/INJURY REPORT NAME OF FACILITY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LIC 624 (Incident/Injury and Death) These binders help ensure that all necessary documentation is easily accessible and well-organized, meeting regulatory requirements and improving administrative efficiency. 08RM-05 34 Report of unusual incident, event, serious injury requiring medical attention, or death, while the resident is under facility supervision, Unusual Incident/Injury/Report (LIC 624). UNUSUAL INCIDENT/INJURY REPORT NAME OF FACILITY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION View, download and print fillable Lic 624-le - Law Enforcement Contact Report in PDF format online. Download Unusual Incident/Injury Report (LIC 624) – Department of Social Services (California) form What reports am I required to submit to licensing? There are two types of reports. View, download and print Lic 624 - Unusual Incident/injury Report pdf template or form online.

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