Form LIC 421IM. Civil Penalty Assessment - Immediate $500 And Repeat Violations - California

Form LIC 421IM is used in California to assess civil penalties against licensed facilities or programs for immediate violations and repeat offenses. The primary purpose of this form is to document and enforce penalties for violations that pose an immediate risk to 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 immediate violation or repeat offense, 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 immediate violation or repeat offense, ensuring adherence to the applicable regulations and guidelines regarding the prevention of harm to individuals in care, determining appropriate penalty amounts based on the severity of the violation and any history of non-compliance, and providing clear explanations or evidence to support the assessment. It is crucial for the DSS representative to promptly address immediate violations, consider the facility's compliance history, and follow established procedures when completing the form to ensure fair enforcement of penalties.

Application Example: A residential care facility in California fails to provide necessary medical intervention during a life-threatening emergency. Form LIC 421IM would be used by the DSS to assess an immediate civil penalty against the facility. By completing the form, the DSS takes swift action to address the immediate violation, protect the well-being of individuals in care, and reinforce the importance of compliance with licensing requirements.

Related Forms: There are no specific related forms mentioned for Form LIC 421IM. However, other incident reporting forms, documentation of corrective actions, and regulatory compliance forms may be used in conjunction with this form to ensure comprehensive enforcement and oversight.