STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
CONFIDENTIAL NAMES
California Statutes and Code of Regulations require that the names of clients/residents not be specified on public documents. The following is a
list of clients/residents referenced in the licensing report identified below.
Date of Field Visit _______________________________________________ Date of the Licensing Report (LIC 809) __________________________________
Date Licensing Report Was Issued/Given To Licensee (Facility Representative) _________________________________________________________________
Facility Name ________________________________________________________ Facility Number _______________________________________________
Name of Client/Resident
*Reference
Number
*REFERENCE NUMBER CORRESPONDS TO NUMBER USED ON THE LICENSING REPORT TO REFER TO CLIENT/RESIDENT.
Licensing Evaluator’s Name(s)(Print) ______________________________________________________________________________ Date_________________________________
Address/Location Comment
Date of
Birth
LIC 811 (8/06)(CONFIDENTIAL)
___________of____________pages
Licensing Evaluator Signature____________________________________________________________________________________
