CA HHSA LIC 624 1999-2025 free printable template

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...

How to fill out ca unusual incident report form

How to fill out CA HHSA LIC 624

1. Obtain the CA HHSA LIC 624 form from the California Department of Social Services website or your local licensing office.
2. Fill in your personal information at the top of the form, including your name, address, and contact details.
3. Indicate the type of care facility you are applying for (e.g., foster care, group home).
4. Provide details about your experience and qualifications in caregiving.
5. List any criminal background or previous licensing issues, if applicable.
6. Include the names and contact information of references who can speak to your qualifications.
7. Sign and date the form at the bottom to certify that all information is true and accurate.
8. Submit the completed form along with any required documentation to your local licensing agency.

Who needs CA HHSA LIC 624?

1. Individuals applying to operate or work in a community care facility in California.
2. Aspiring foster parents seeking approval for caregiving.
3. Organizations looking to establish group homes or similar facilities.

People Also Ask about lic unusual incident report

What are unusual incident injury report form used for?

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.

What is an example of an unusual incident?

UNUSUAL EVENT OR INCIDENT: Unusual incidents include resident abuse, unexplained absences, or anything that affects the physical or emotional health or safety of any resident and epidemic outbreaks, poisonings, catastrophes, facility fires or explosions.

What is an unusual occurrence incident report?

The unusual occurrence report is a guide to walk through a thorough investigation for a root cause analysis. An unusual occurrence report is to be completed for all injuries/accidents or any situation/occurrence that could pose a safety risk to patients or staff.

What is LIC 624?

LIC 624 - Unusual Incident/Injury Report.

Which of the following is an unusual incident?

Unusual Incident means incidents involving serious illness or accidents, death of an individual, injury or illness of an individual requiring inpatient or emergency hospitalization, suicide attempts, a fire requiring the services of a fire department, an act of physical aggression, or any incident requiring abuse

What is an example of unusual occurrence?

Unusual Occurrence means events or situations that do not happen daily or that may have had an impact on children. such as: fire drill interrupted sleep, visitor came with puppets, fear of a dog on a walk. It may by something that happened to the whole group of children or just to an individual child.

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What is CA HHSA LIC 624?

CA HHSA LIC 624 is a form used in California for reporting certain activities related to licensed residential care facilities, including adult and children's residential facilities.

Who is required to file CA HHSA LIC 624?

Licensed residential care facility operators in California are required to file CA HHSA LIC 624 to report relevant information and changes regarding their facility.

How to fill out CA HHSA LIC 624?

To fill out CA HHSA LIC 624, carefully complete each section of the form, providing accurate and complete information as required. Follow the specific instructions provided with the form.

What is the purpose of CA HHSA LIC 624?

The purpose of CA HHSA LIC 624 is to collect essential data about residential care facilities to ensure compliance with state regulations and to facilitate monitoring and oversight.

What information must be reported on CA HHSA LIC 624?

The information that must be reported on CA HHSA LIC 624 includes the facility's name, address, license number, types of care provided, capacity, and any changes in administration or ownership.