Form LIC 421D (ASC). Civil Penalty Assessment - Death/Serious Bodily Injury/Physical Abuse (ASC) - California

Form LIC 421D (ASC) is used in California to assess civil penalties against licensed facilities or programs in cases involving death, serious bodily injury, or physical abuse. The main purpose of this form is to document and enforce penalties for severe incidents that jeopardize the health, safety, or well-being of individuals under care.

The form consists of sections where the Department of Social Services (DSS) assesses the civil penalties against the facility or program. This may include details such as the facility's name, location, nature of the incident, 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 incident details, ensuring adherence to the applicable regulations and guidelines regarding the prevention of death, serious bodily injury, or physical abuse, determining appropriate penalty amounts based on the severity of the incident and any prior history 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: A residential care facility in California experiences a case where a resident sustains a severe injury due to neglect by staff members. Form LIC 421D (ASC) would be used by the DSS to assess civil penalties against the facility. By completing the form, the DSS addresses the incident, holds the facility accountable for the harm caused, and works to prevent future occurrences of neglect or abuse.

Related Forms: There are no specific related forms mentioned for Form LIC 421D (ASC). However, other incident reporting forms, investigation documentation, and regulatory compliance forms may be involved in conjunction with this form to ensure a comprehensive assessment of the incident and appropriate enforcement actions.