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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
DEATH REPORT
LICENSEE MUST REPORT THE DEATH OF A CLIENT
OF ANY CAUSE, REGARDLESS OF WHERE THE
DEATH OCCURRED.
INSTRUCTIONS : NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND
RESPONSIBLE PERSONS, IF ANY, BY NEXT WORKING DAY.
SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE.
RETAIN COPY OF REPORT IN CLIENT’S FILE.
NAME OF FACILITY
FACILITY FILE NUMBER
TELEPHONE NUMBER
( )
ADDRESS CITY, STATE, ZIP
CLIENT’S NAME
D.O.B. SEX DATE OF ADMISSION
DATE AND TIME OF DEATH PLACE OF DEATH
DESCRIBE IMMEDIATE CAUSE OF DEATH (IF CORONER REPORT MADE, SEND COPY WITHIN 30 DAYS):
DESCRIBE CONDITIONS PRIOR TO OR CONTRIBUTING TO DEATH:
EXPLAIN WHAT IMMEDIATE ACTION WAS TAKEN (INCLUDE PERSONS CONTACTED):
MEDICAL TREATMENT NECESSARY?
YES ■■
NO
IF YES, GIVE NATURE OF TREATMENT:
NAME OF ATTENDING PHYSICIAN NAME OF MORTICIAN
REPORT SUBMITTED BY:
NAME AND TITLE DATE
REPORT REVIEWED/APPROVED BY:
NAME AND TITLE DATE
AGENCIES/INDIVIDUALS NOTIFIED (SPECIFY NAME AND TELEPHONE NUMBER)
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LICENSING______________________________________
ADULT/CHILD PROTECTIVE SERVICES________________________
ONG TERM CARE OMBUDSMAN___________________
PARENT/GUARDIAN/CONSERVATOR__________________________
LAW ENFORCEMENT_____________________________
PLACEMENT AGENCY______________________________________
