Form LIC 421A. Civil Penalty Assessment (Unlicensed Facility) - California

Form LIC 421A is used in California to assess civil penalties against unlicensed facilities that operate without proper licensing or certification. The main purpose of this form is to document and enforce penalties for non-compliance with licensing requirements.

The form consists of sections where the Department of Social Services (DSS) assesses the civil penalties against the unlicensed facility. This may include details such as the facility's name, location, nature of violations, applicable regulations, penalty amounts, and any additional information or documentation related to the case. The form may also provide spaces for the DSS representative's signature and date.

Important fields on this form include accurately documenting the violation details, ensuring adherence to the applicable regulations and guidelines, determining appropriate penalty amounts based on the severity and frequency of non-compliance, and providing clear explanations or evidence to support the assessment. It is crucial for the DSS representative to conduct a thorough investigation and follow established procedures when completing the form to ensure fair enforcement of penalties.

Application Example: The Department of Social Services in California discovers an unlicensed residential care facility operating without proper certification. Form LIC 421A would be used to assess civil penalties against the facility, taking into account the violations committed and the potential risk to the residents' health and safety. By completing the form, the DSS takes necessary actions to address non-compliance and protect vulnerable individuals from unauthorized operations.