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

The LIC 421D form is specifically designed by the California Department of Social Services for assessing civil penalties in cases involving death, serious bodily injury, or physical abuse. It serves as a legal instrument to document and evaluate instances where licensed facilities or individual caregivers are held accountable for causing severe bodily harm to children or adults under their supervision. The form captures essential details and evidence related to the incident, including the extent and nature of the bodily injuries inflicted, as well as any relevant information concerning the abuse or neglect. By utilizing this form, the Department can conduct a comprehensive investigation, determine liability accurately, and impose appropriate civil penalties to ensure compliance with regulations and safeguard the welfare of vulnerable individuals.