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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. SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE. RETAIN COPY OF REPORT IN CLIENT S FILE. NAME OF FACILITY FACILITY FILE NUMBER ADDRESS CITY STATE ZIP TELEPHONE NUMBER CLIENTS/RESIDENTS INVOLVED TYPE OF INCIDENT s Unauthorized...
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INITIAL APPOINTMENT TIME. 0 0 DAYS 1 2 3 4 DAYS 5 6 7 8 9 DAYS 30 DAYS 60 DAYS. FIVE-DAY NOTICE TO REMAIN DURING INACTIVE PERIODS. 2 PERIODS. NOTIFICATION OF INACTIVE DATES. INFORM SION PERIOD. INITIAL APPOINTMENT TIME. THE DAY OF APPLICATION. APPLICATION DEADLINE. 15 MINUTES. DATE OF ADMISSION. LIC 624 (4/99). TYPE OF INCIDENT s Unauthorized Absence. Alleged Client Abuse s Rape s Injury-Accident s Medical Emergency. INITIAL APPOINTMENT TIME. 0 0 DAYS 1 2 3 4 DAYS 5 6 7 8 9 DAYS 30 DAYS 60 DAYS. FIVE-DAY NOTICE TO REMAIN DURING INACTIVE PERIODS. 2 PERIODS. NOTIFICATION OF INACTIVE DATES. INFORM SION PERIOD. INITIAL APPOINTMENT TIME. THE DAY OF APPLICATION. APPLICATION DEADLINE. 15 MINUTES. DATE OF ADMISSION. LIC 624 (4/99). TYPE OF INCIDENT s Unauthorized Absence. Alleged Client Abuse s Rape s Injury-Accident s Medical Emergency. INITIAL APPOINTMENT TIME. 0 0 DAYS 1 2 3 4 DAYS 5 6 7 8 9 DAYS 30 DAYS 60 DAYS. FIVE-DAY NOTICE TO REMAIN DURING INACTIVE PERIODS. 2 PERIODS. NOTIFICATION OF INACTIVE DATES. INFORM SION PERIOD. INITIAL APPOINTMENT TIME. THE DAY OF APPLICATION. APPLICATION DEADLINE. 15 MINUTES. DATE OF ADMISSION. LIC 624 (4/99). TYPE OF INCIDENT s Unauthorized Absence. Alleged Client Abuse s Rape s Injury-Accident s Medical Emergency. INITIAL APPOINTMENT TIME. 0 0 DAYS 1 2 3 4 DAYS 5 6 7 8 9 DAYS 30 DAYS 60 DAYS. FIVE-DAY NOTICE TO REMAIN DURING INACTIVE PERIODS. 2 PERIODS. NOTIFICATION OF INACTIVE DATES. INFORM SION PERIOD. INITIAL APPOINTMENT TIME.
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