Form Lic 624-Le - Law Enforcement Contact Report
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4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
LAW ENFORCEMENT
INSTRUCTIONS: NOTIFY LICENSING AGENCY, PLACEMENT AGENCY
AND AUTHORIZED REPRESENTATIVE, IF ANY, BY NEXT
CONTACT REPORT
BUSINESS DAY.
THIS FORM MAY BE USED TO REPORT
SUBMIT PART 1 OF THIS REPORT WITHIN 7 DAYS OF OCCURRENCE.
INCIDENTS AS REQUIRED BY HEALTH AND
SUBMIT PART 2 OF THIS REPORT WITHIN 6 MONTHS OF
SAFETY CODE SECTION 1538.7. A SEPARATE
OCCURRENCE. PART 2 MAY BE SUBMITTED SOONER THAN 6 MONTHS,
UNUSUAL INCIDENT REPORT DOES NOT
INCLUDING CONCURRENTLY WITH THE INITIAL REPORT, IF ALL
NEED TO BE SUBMITTED IF ALL REQUIRED
OUTCOMES RESULTING FROM THE INCIDENT ARE KNOWN.
INFORMATION IS PROVIDED.
PART 1
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Group Home
Runaway and Homeless
STRTP
Community Treatment
Transitional Housing
Facility
Youth Shelter
Placement Provider
Licensed Capacity: _______________
Current Census: __________________
NAME OF FACILITY (as appears on license)
FACILITY LICENSE NUMBER
ADDRESS
TELEPHONE NUMBER
COUNTY, CITY, STATE, ZIP
DATE OF INCIDENT
TYPE OF INCIDENT
(check all that apply)
Aggressive Act:
Other:
Alleged Client Abuse:
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Client to Client
Staff to Client
Behavior Episode
Psychological
Sexual
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Client to Other
Unknown
Substance Abuse
Property Damage
Physical
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Client to Staff
Other to Client
Unauthorized
Non-physical Aggression
Psychological
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Absence (AWOL)
Theft
Financial
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Harm To Self
Other: ________________
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Neglect
CHILD INVOLVED
TYPE OF PLACEMENT AGE
GENDER
DATE OF ADMISSION
_________________________________________________________________________________________________
Choose One
Choose One
_________________________________________________________________________________________________
Choose One
Choose One
_________________________________________________________________________________________________
Choose One
Choose One
_________________________________________________________________________________________________
Choose One
Choose One
AGENCIES / INDIVIDUALS NOTIFIED
NAME
PHONE
LICENSING
LAW ENFORCEMENT
PLACEMENT AGENCY
AUTHORIZED REPRESENTATIVE
IF A POLICE REPORT WAS FILED, PROVIDE NUMBER IF KNOWN (Optional)_________________________________
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WERE DE-ESCALATION TECHNIQUES USED PRIOR TO CONTACTING LAW ENFORCEMENT?
YES
NO
IF YES, EXPLAIN THE TECHNIQUES THAT WERE USED. IF NO, EXPLAIN WHY NOT.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
PAGE 1 OF 4
LIC 624-LE (4/17)
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Parent category: Legal