Fillable CONTACT SHEET (California CDSS)

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CONTACT SHEET (California CDSS)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
CONTACT SHEET
This form is intended to document contacts concerning the facility identified below. Such contacts may include
notification of corrections by the facility. Limit information to public information. File on the top right side of
the facility folder. Enter t/c (telephone call) or o/v (other visit) and the contact date in the first column. Under
Summary of Contacts enter relevant information including action taken and follow up. Enter initial and last
name after each entry.
FACILITY NAME
FACILITY NUMBER
TYPE CONTACT/
DATE (t / c, o / v)
SUMMARY OF
CONTACTS
LIC 185 (5/99) (PUBLIC) Continue on back if necessary
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CONTACT SHEET (California CDSS)

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Completed 7 September 2020

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