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

The LIC 421D form is used by the California Department of Social Services to assess civil penalties in cases involving death, serious injury, or physical abuse. This form is typically utilized when a licensed facility or individual caregiver is found responsible for incidents resulting in the death or significant harm to a child or adult under their care. The form serves as an official document to document the evidence and details surrounding the incident, including the nature of the injuries sustained and any pertinent information related to the abuse or neglect. It enables the Department to investigate the matter thoroughly, determine liability, and impose appropriate civil penalties to ensure accountability and promote the safety and well-being of vulnerable individuals.