Fillable REPORT UNUSUAL INCIDENT/INJURY (California)

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REPORT UNUSUAL INCIDENT/INJURY (California)

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I
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
UNUSUAL INCIDENT/INJURY
REPORT
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
CLIENTS/RESIDENTS INVOLVED DATE OCCURRED
AGE SEX DATE OF ADMISSION
TYPE OF INCIDENT
Unauthorized Absence Alleged Client Abuse Rape Injury-Accident Medical Emergency
Aggressive Act/Self Sexual Pregnancy Injury-Unknown Origin Other Sexual Incident
Aggressive Act/Another Client Physical Suicide Attempt Injury-From another Client Theft
Aggressive Act/Staff Psychological Other Injury-From behavior episode Fire
Aggressive Act/Family, Visitors Financial Epidemic Outbreak Property Damage
Alleged Violation of Rights Neglect Hospitalization Other (explain)
DESCRIBE EVENT OR INCIDENT (INCLUDE DATE, TIME, LOCATION, PERPETRATOR, NATURE OF INCIDENT, ANY ANTECEDENTS LEADING UP TO INCIDENT AND HOW CLIENTS WERE AFFECTED, INCLUDING
ANY INJURIES:
PERSON(S) WHO OBSERVED THE INCIDENT/INJURY:
EXPLAIN WHAT IMMEDIATE ACTION WAS TAKEN (INCLUDE PERSONS CONTACTED):
LIC 624 (4/99)
OVER
MEDICAL TREATMENT NECESSARY? YES NO IF YES, GIVE NATURE OF TREATMENT:
WHERE ADMINISTERED: ADMINISTERED BY:
FOLLOW-UP TREATMENT, IF ANY:
ACTION TAKEN OR PLANNED (BY WHOM AND ANTICIPATED RESULTS:
LICENSEE/SUPERVISOR COMMENTS:
NAME OF ATTENDING PHYSICIAN
REPORT SUBMITTED BY:
NAME AND TITLE DATE
REPORT REVIEWED/APPROVED BY:
NAME AND TITLE DATE
AGENCIES/INDIVIDUALS NOTIFIED (SPECIFY NAME AND TELEPHONE NUMBER)
LICENSING
______________________________________
ADULT/CHILD PROTECTIVE SERVICES
________________________
LONG TERM CARE OMBUDSMAN
___________________
PARENT/GUARDIAN/CONSERVATOR
__________________________
LAW ENFORCEMENT
_____________________________
PLACEMENT AGENCY_
_____________________________________
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REPORT UNUSUAL INCIDENTINJURY (California)

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Completed 15 December 2020

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