Ca Death Report – Fill Out and Use This PDF

Updated: Oct 31, 2026

The California Death Report Form, issued by the State of California Health and Human Services Agency, California Department of Social Services Community Care Licensing Division, is a vital document designed to ensure the timely notification and comprehensive documentation of a client's death in community care facilities. This form mandates that responsible parties, including the licensing agency, placement agency, and licensee, report the death of a client by the next working day and submit a written report within seven days of occurrence. To complete this essential process and adhere to the required protocols, click the button below.

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Ca Death Report PDF Details

In the realm of healthcare and social services, the State of California ensures the well-being and safety of clients under the care of various facilities through meticulous documentation and reporting procedures. Among these, the California Death Report form, overseen by the California Department of Social Services' Community Care Licensing Division, stands out as a critical tool for accountability and transparency. This form is intended for the use of licensed facilities to report the death of a client, covering a gamut of details from basic information such as the client's name, date of birth, and sex, to more specific data including the date, time, and place of death, as well as the immediate cause of death. Facilities are required to notify the licensing agency, placement agency, and responsible persons, if any, by the next working day following the death, and must submit a written report within seven days of the occurrence. This procedure ensures that relevant authorities and involved parties are promptly informed, while also mandating facilities to retain a copy of the report in the client's file for record-keeping purposes. Additionally, the form prompts facilities to describe any medical treatment necessary prior to the death, actions taken immediately afterward, and notifications made to agencies and individuals, promoting a comprehensive review of the circumstances surrounding each case.

Question	Answer
Form Name	Ca Death Report
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	lic 624a, ca form death blank, death licensing online, ca death report

How to Fill Out Form LIC 624A

Form LIC 624A at a glance

What it is: The Death Report is a form of the California Department of Social Services, Community Care Licensing Division.

Where and when to file: Submit the written report within 7 days of occurrence.

The licensee must report the death of a client of any cause, regardless of where the death occurred.

A filled-in Form LIC 624A example: a licensee reports a client's death

Form LIC 624A example filled out, example: a licensee reports a client's death — A licensee fills out the Death Report, form LIC 624A. The client died in the facility, so the written report goes out within 7 days of occurrence. The picture shows the filled form, and all its values are invented. The client received medical treatment, so NO stays empty. Only Licensing and Placement Agency were notified, so the other boxes under Agencies/individuals notified stay empty.

How to fill out Form LIC 624A, box by box

Name of Facility, address and telephone number

Enter the Name of Facility, the Facility File Number and the Telephone Number.

Enter the Address and the City, State, Zip.

Client's name, admission and death

Enter the Client's Name, the Sex and the Date of Admission.

Enter the Date and Time of Death and the Place of Death.

Cause of death, conditions and immediate action

Describe the immediate cause of death. If a coroner report is made, send a copy within 30 days.

Describe the conditions prior to or contributing to death.

Explain what immediate action was taken, including the persons contacted.

Medical treatment necessary?

For Medical treatment necessary?, mark YES or NO. If YES, give the nature of treatment.

Enter the Name of Attending Physician and the Name of Mortician.

Report submitted by and reviewed/approved by

Under Report Submitted By, enter the Name and Title and the Date.

Under Report Reviewed/Approved By, enter the Name and Title and the Date.

Agencies/individuals notified

Under Agencies/Individuals Notified, specify the name and telephone number.

Mark the box for Licensing, Adult/Child Protective Services, Long Term Care Ombudsman, Parent/Guardian/Conservator, Law Enforcement or Placement Agency.

More rules for Form LIC 624A

Notify the licensing agency, placement agency and responsible persons, if any, by next working day.

Retain a copy of the report in the client's file.

Common questions about Form LIC 624A

Is there a deadline?

Submit the written report within 7 days of occurrence.

Sources

[1] Form LIC 624A (7/99), Death Report, California Department of Social Services (the Official source link on this page).