LIC 421A - Civil Penalty Assessment

Form LIC 421A is used for the assessment of civil penalties against licensed facilities in California. The form is completed by the California Department of Social Services (CDSS) to notify the facility operator or licensee of the assessed civil penalty, including the violation(s) committed, the amount of the penalty, and instructions for making the payment. By utilizing this form, the CDSS communicates the penalty assessment and ensures that facilities are held accountable for non-compliance with regulatory requirements.