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TYPE OF INCIDENT
Aggressive Act: Alleged Client Abuse:
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Unauthorized Absence
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Self
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Sexual
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Rape
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Theft
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Another Client
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Physical
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Suicide Attempt
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Fire
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Staff
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Psychological
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Injury-From Another Client
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Property Damage
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Family, Visitors
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Financial
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Injury-From Behavior Episode
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Alleged Violation of Rights
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Neglect
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Other Sexual Incident
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Other (Explain:) ___________________________________________________________________________________________
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
LAW ENFORCEMENT
CONTACT REPORT
THIS FORM MAY BE USED TO REPORT
INCIDENTS AS REQUIRED BY HEALTH AND
SAFETY CODE SECTION 1538.7. A SEPARATE
UNUSUAL INCIDENT REPORT DOES NOT
NEED TO BE SUBMITTED IF ALL REQUIRED
INFORMATION IS PROVIDED.
INSTRUCTIONS: NOTIFY LICENSING AGENCY, PLACEMENT
AGENCY AND AUTHORIZED
REPRESENTATIVE, IF ANY, BY NEXT
BUSINESS DAY.
SUBMIT PART 1 OF THIS REPORT WITHIN 7
DAYS OF OCCURRENCE.
SUBMIT PART 2 OF THIS REPORT WITHIN 6
MONTHS OF OCCURRENCE.
PART 1
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Group Home
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STRTC
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Community Treatment
Facility
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Transitional Housing
Placement Provider
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Runaway and Homeless
Youth Shelter
NAME OF FACILITY FACILITY LICENSE NUMBER
ADDRESS TELEPHONE NUMBER
CITY, STATE, ZIP DATE OF INCIDENT
CHILD INVOLVED AGE GENDER DATE OF ADMISSION
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AGENCIES / INDIVIDUALS NOTIFIED NAME PHONE
LICENSING
LAW ENFORCEMENT
PLACEMENT AGENCY
AUTHORIZED REPRESENTATIVE
IF A POLICE REPORT WAS FILED, PROVIDE NUMBER IF KNOWN (Optional)_________________________________
DESCRIPTION OF INCIDENT. INCLUDE NATURE OF INCIDENT, ACTION TAKEN BY STAFF IN RESPONSE TO THE
INCIDENT, AND DISPOSITION OR CURRENT STATUS OF THE INCIDENT. FOR INCIDENTS IN GROUP HOMES,
INCLUDE A DESCRIPTION OF THE EVENTS LEADING UP TO THE INCIDENT.
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LIC 624-LE (4/16)
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