Form Lic 9029a - Statement Of Facts Summary Sheet Page 8
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9SOF SUMMARY SHEET INSTRUCTIONS
(Continued)
14 Financial Abuse: Misuse of client cash resources such as P&I, gifts, SSI/SSP checks or failure to protect client’s personal
property.
15 Level of Care: Accepting/retaining clients requiring higher level of care than allowed in a non-medical facility or by the
license.
16 Qualifications: Persons providing services not meeting required qualifications.
17 Financial Issues: Lack of resources to operate facility within licensing requirements or other non-client financial issues.
18 Questionable Death: Client’s death where it appears the facility could have been responsible or could have done more to
prevent death.
19 Other: All violations which do not fit into other categories.
21 Ritualistic Abuse: Physical, emotional, psychological, sexual abuse in a ritualistic manner.
22 Physical Punishment: Spanking on bottom, slapping on back of hand, etc. (not rising to the level of #01 Physical Abuse
above).
23 CACI Match: Actions taken as a result of a CACI match and subsequent substantiated violation.
24 Conduct Inimical: Conduct which is inimical to the heath, morals, welfare, or safety of either an individual in, or receiving
services from, the facility or the people of the State of California.
25. Failure To Pay Initial and/or Annual Fees.
TYPE OF ACTION REQUESTED:
01 Denied Application: Denial of an application. OK to include Attorney Review (06) if necessary. However, for any other
actions taken against the same licensee (i.e., revoking additional licenses), a SOF Summary Sheet must be completed for
each action.
02 Telephone TSO: Imminent danger has been established and an attorney is assigned prior to receiving case. Note above
reference to Telephone TSO. Must include Revocation (04).
03 TSO: Imminent danger has been established. Must include Revocation (04); Ok to include Attorney Review (06).
04 Revocation: License is to be revoked. OK to include Attorney Review (06). However, for any other actions taken against
the same license (i.e., revoking additional licenses or excluding an employee, etc.), an additional SOF Summary Sheet
must be completed for each action.
41 Expedited Revocation: Use to request priority action on an accusation.
05 Injunction/TRO: Request to legal to request the court to enjoin or temporarily restrain a facility from operating without a
license.
06 Attorney Review: Use when requesting attorney review. Most often is used in conjunction with another action type.
08 Revoke Probl.: Probation is to be revoked. OK to include Attorney Review (06).
09 FFA Certified Family Home Action: Use when de-certifying or requesting that a home not be certified.
11 Immediate Exclusion - Employee: Use when an employee has been or will be immediately excluded. Must complete
date served and attorney consulted. OK to include Attorney Review (06) when letter has not been served.
12 Immediate Exclusion - Administrator: Use when an Administrator has been or will be immediately excluded. Must
complete date served and attorney consulted. OK to include Attorney Review (06) when letter has not been served.
13 Immediate Exclusion - Other: Use when a family member or non-client adult has been or will be immediately excluded.
Must complete date served and attorney consulted. OK to include Attorney Review (06) when letter has not been served.
14 Non-Immediate Exclusion - Employee: Use to request non-immediate exclusion of an employee. OK to include
Attorney Review (06).
15 Non-Immediate Exclusion - Administrator: Use to request non-immediate exclusion of an Administrator. OK to include
Attorney Review (06).
16 Non-Immediate Exclusion - Other: Use to request non-immediate exclusion of a licensee, board member, family
member or non-client adult. Ok to include Attorney Review (06).
17 Denied Exemption Action: To be used by CBCB when a criminal record exemption has been denied. Could be used in
conjunction with immediate or non-immediate exclusion.
18 Administrator Decertification: Not currently being used. Reserve for future use.
Page 8 of 9
LIC 9029A (1/08)
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