Form Lic 421d(Asc) - Civil Penalty Assessment - Death/serious Bodily Injury/physical Abuse (Asc) Page 2
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CIVIL PENALTY ASSESSMENT – DEATH / SERIOUS BODILY INJURY / PHYSICAL ABUSE
EXPLANATION TO LICENSEE
An investigation was conducted at the above facility by a licensing evaluator. During that investigation a violation of licensing
statute and/or regulation was identified. It has been determined that this violation has resulted in the death or serious bodily
injury of a client, or constitutes physical abuse of a client, resulting in a civil penalty specified in California Health and Safety
Code Section 1548(e) or (f), 1568.0822(e) or (f), or 1569.49(e) or (f). The decision to assess a civil penalty has been
approved by a Program Administrator of the Community Care Licensing Division, as indicated on the front of this form.
If a civil penalty has already been assessed for the underlying violation that resulted in the death or serious bodily injury, only
the larger civil penalty amount will apply. If the amount of the civil penalty on this form exceeds the amount of the civil penalty
already assessed for the underlying violation, only the civil penalty amount indicated on this form will be due. If the amount of
the civil penalty that the Department has already assessed for the underlying violation exceeds the amount of the penalty
indicated on this form, the already assessed amount will prevail and be due and payable as already assessed by the
Department.
You will receive an invoice in the mail once administrative appeals have been exhausted. Payment is due upon receipt of
invoice. Unless payment arrangements have been made that are acceptable to the Department, a civil penalty not paid within
30 days of being billed will be subject to late fees. Payment must be made by check or money order made payable to the
“California Department of Social Services”. Please write the facility number and invoice number on your check.
DO NOT SEND CASH.
NOTE: In addition to the imposition of civil penalties, California Health and Safety Code Sections 1550 and 1569.50 also
authorize the suspension or revocation of a license based on licensing violations.
APPEAL RIGHTS
The licensee has a right without prejudice to discuss any disagreement concerning the proper application of licensing laws
and regulations with the Department. The licensee may also request a formal administrative review of the civil penalty
assessed on this form. The licensee and Department shall adhere to the timeline listed below:
• Within 15 business days of receipt of this form, the licensee may request a formal review of the civil penalty by the
Deputy Director of the Community Care Licensing Division. The request must be in writing, and must include all
available supporting documentation.
• Within 30 business days of the request for review, the licensee may submit any additional supporting documentation
that was unavailable at the time of the initial request. The licensee may request an office interview to provide
additional information.
• Within 30 business days of receiving the initial request from the licensee, the Department may request any additional
information from the licensee deemed necessary to make its determination. The licensee shall provide this additional
information within 30 business days of receiving the Department’s request.
• Within 60 business days of the date when all necessary information has been provided to the Department by the
licensee, the licensee shall be notified in writing of the Department’s decision.
The Department has a duty to review the facts presented without prejudice. Upon review of the facts, the Department may
amend or dismiss the civil penalty or finding of deficiency.
Upon exhausting this review, the licensee may further appeal the Department’s decision to an Administrative Law Judge.
Appeals to an Administrative Law Judge follow a separate procedure, conducted in accordance with Chapter 5 (commencing
with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code.
LIC 421D(ASC) (6/17)
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