Form Lic 9029a - Statement Of Facts Summary Sheet Page 7
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9STATEMENT OF FACTS (SOF) SUMMARY SHEET INSTRUCTIONS
THE SOF SUMMARY SHEET PROVIDES BASIC INFORMATION TO BE ENTERED INTO THE LEGAL CASE TRACKING
SYSTEM (LCTS). THE LCTS PROVIDES A MECHANISM FOR TRACKING LEGAL CASES THROUGHOUT THE
PROCESS.
TO BE COMPLETED BY PROGRAM OFFICE:
Legal Case Number: Enter a 9 to 11 digit case number, which remains with case throughout legal action.
PROGRAM: Enter appropriate program - Child Care, Childrens Residential, Adult Care, Senior Care
Appeal Rec’d: Enter date Program Office received appeal for: exclusion, de-certification, denial of application, or denial of
exemption.
Acknowledgment Letter Sent: Enter date acknowledgment letter was sent to appellant.
SOF Due: Enter date SOF is due from R.O., CBCB, or County staff.
TO BE COMPLETED BY R.O./COUNTY:
Facility number: Enter facility number that R.O./County has assigned to facility.
Capacity: Enter capacity for which facility is licensed.
Operating?: Circle yes if facility is currently operating. Circle no if facility is not currently operating.
Facility type: Check appropriate facility type.
Decertified or Excluded Individual: Enter last name/first name, address, and phone number of decertified or excluded
individual.
FFA Certified Family Home: Enter the name, address, and phone number of the Certified Family Home (last name/first
name) when an FFA decertification action is being taken.
Licensee Name: Enter licensee’s last name/first name, (or corporate name as shown on license), mailing address, and phone
number.
Facility Name: Enter facility’s name (as shown on license), address, and phone number.
Telephone TSO: Enter assigned attorney’s name and date approved by Program Administrator.
Immediate Exclusion: Enter date letter was sent to individual and the name of attorney that was consulted.
Date first licensed: Enter date the first license was issued.
# of other facilities: If licensee operates more than one facility, enter the number of additional facilities and attach an
additional summary sheet and LIS profile for each facility. Enter “O” if there are no other facilities.
VIOLATIONS:
01 Physical Abuse: Subject kicking, punching, slapping, hitting, hitting with an object, squeezing, pushing, with intent to do
physical harm to victim.
02 Sexual Abuse: Inappropriate sexual activity between a client and non-client including rape, molestation, sodomy,
voyeurism, pornography or sexual harassment.
03 Other Personal Rights/Restraint: Verbal or emotional abuse (excluding #22 Physical Punishment below), intimidation,
interference with daily living such as eating or sleeping, locking clients in or out or using other restraints.
04 Unlicensed: Providing unlicensed care.
05 Fire Clearance: Operating a facility without an appropriate fire clearance.
06 Crimes - no arrest: Criminal conduct which did not result in an arrest or conviction.
61 Crimes - Conv Exempt Denied: Denial of exemption due to conviction.
62 Crimes - Non Exemptible: Denial of exemption due to non-exemptible crime.
63 Crimes - Arrest Only: Action taken as a result of the arrest only investigation.
07 Physical Plant: Unsafe or unsanitary buildings or grounds including unfenced pool, poor repair, heating, lighting, cooling,
or lack of phone or signal system.
08 Record Keeping: Inadequate client or staff records including medical, staff qualifications, admission agreement, or other
required records.
09 License/Capacity: Operating beyond terms of license including overcapacity. Excludes Level of care.
10 Neglect/Lack of Supervisor: Lack of adequate staff to provide aid with daily living including dressing, bathing, feeding,
transportation, or medical needs. Failure to protect clients from harm.
11 Food Service: Failure to provide adequate food service including poor food, special diets, menu planning, etc.
12 False Statements: Providing false information on application, lying about facility incidents or submitting false reports
about clients.
13 Medications: Mishandling of medications including poor storage, dispensing, labeling or record keeping.
Page 7 of 9
LIC 9029A (1/08)
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