Lic 624 Death Report. INSTRUCTIONS : NOTIFY LICENSING AGENCY, PLACEMENT Fill out and downlo

INSTRUCTIONS : NOTIFY LICENSING AGENCY, PLACEMENT Fill out and download the LIC624A Death Report form in California. Notify Licensing by telephone, fax, or e-mail before end of next working day. 7(a) of the Health and Safety Code, “A group home, transitional housing place-ment provider, community treatment facility, (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 Previously incidents, injuries and deaths were reported on one form, the LIC 624. Keep a copy of the Learn about the CA Death Report form, its purpose, and how to complete it efficiently to ensure accurate reporting. As of 1-99 there will be two reporting forms, the LIC 624, for incidents and injuries only, and the LIC 624A for deaths. INSTRUCTIONS : NOTIFY LICENSING AGENCY, PLACEMENT LICENSEE MUST REPORT THE DEATH OF A CLIENT OF ANY CAUSE, REGARDLESS OF WHERE THE DEATH OCCURRED. If reported to the Department by telephone, submit written report within 7 calendar days of the event. The Download Death Report (LIC 624A) – Department of Social Services (California) form Discover how to easily obtain and fill out a CA death report form with our DESCRIBE IMMEDIATE CAUSE OF DEATH (IF CORONER REPORT MADE, SEND COPY WITHIN 30 DAYS): DESCRIBE CONDITIONS PRIOR TO OR CONTRIBUTING TO DEATH: Complete in report Sections I, II and/or III as appropriate. If reported by telephone, submit written report within 7 calendar days of the incident/injury to Licensing. Within the next business day, notify the Department by telephone or fax of the events listed in #11. This report is crucial for beneficiaries 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. It is crucial to follow the proper DESCRIBE IMMEDIATE CAUSE OF DEATH (IF CORONER REPORT MADE, SEND COPY WITHIN 30 DAYS): DESCRIBE CONDITIONS PRIOR TO OR CONTRIBUTING TO DEATH: EXPLAIN WHAT Alternate Names: LIC Injury Report Form; LIC Unusual Incident Report Form. Edit, sign, and share lic 624 online. UNUSUAL EVENT OR INCIDENT: Unusual incidents include resident abuse, unexplained absences, or anything that affects the physical or DESCRIBE IMMEDIATE CAUSE OF DEATH (IF CORONER REPORT MADE, SEND COPY WITHIN 30 DAYS): The LIC 624A form, also known as the Death Report, is essential for reporting the death of clients in California's care facilities. This guide will provide clear, step-by-step The LIC 624 death report is a document issued by life insurance companies to provide evidence of a policyholder's death. The LIC 624 death report is a document issued by life insurance companies to provide evidence of a policyholder's death. This report is crucial for beneficiaries LIC 624, Unusual Incident/Injury Report Updated December 2025 , UCSF California Childcare Health Program Death Other (explain) DESCRIBE EVENT OR INCIDENT (INCLUDE DATE, TIME, LOCATION, PERPETRATOR, NATURE OF INCIDENT, ANY ANTECEDENTS LEADING UP TO INCIDENT AND How to fill out the CA LIC 624A online Filling out the CA LIC 624A is an essential process for reporting the death of a client in a licensed facility within California. LICENSEE MUST REPORT THE DEATH OF A CLIENT OF ANY CAUSE, REGARDLESS OF WHERE THE DEATH OCCURRED. 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). I. The LIC 624 Form was released by the Community Care Licensing Division of the Access the most up-to-date revision of ca death report • Customize, fill in, and send online • Incredible list of various templates and forms. ABOUT THE LIC 624-LE THE LAW: In accordance with section 1538. Get essential tips and guidelines here. No need to install software, just go to DocHub, and sign up instantly and for free. View, download and print Lic 624 - Unusual Incident/injury Report pdf template or form online. Create a 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 Filling out the CA LIC 624A is an essential process for reporting the death of a client in a licensed facility within California. 469 California Legal Forms And Templates are collected for any of .

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