LIC 421D - Civil Penalty Assessment Death/Serious Bodily Injury/Physical Abuse

Form LIC 421D is a civil penalty assessment form used by the California Department of Social Services (CDSS) in cases involving death, serious bodily injury, or physical abuse in licensed facilities. The form is completed by the CDSS to notify the facility operator or licensee about the assessed civil penalty due to these grave incidents. It includes information about the specific violation(s), the amount of the penalty, and instructions for payment. By utilizing this form, the CDSS enforces accountability for severe violations, ensures compliance with regulations to prevent harm, and promotes the safety and well-being of individuals receiving care in licensed facilities.