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.

QuestionAnswer
Form NameCa Death Report
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameslic 624a, ca form death blank, death licensing online, ca death report

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING DIVISION

DEATH REPORT

INSTRUCTIONS : NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND

LICENSEE MUST REPORT THE DEATH OF A CLIENT

 

RESPONSIBLE PERSONS, IF ANY, BY NEXT WORKING DAY.

 

 

 

 

 

 

OF ANY CAUSE, REGARDLESS OF WHERE THE

 

SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE.

DEATH OCCURRED.

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND TITLE

 

 

 

 

 

DATE

REPORT SUBMITTED BY:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND TITLE

 

 

 

 

 

DATE

REPORT REVIEWED/APPROVED BY:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCIES/INDIVIDUALS NOTIFIED (SPECIFY NAME AND TELEPHONE NUMBER)

LICENSING______________________________________ ADULT/CHILD PROTECTIVE SERVICES________________________

LONG TERM CARE OMBUDSMAN___________________ PARENT/GUARDIAN/CONSERVATOR__________________________

LAW ENFORCEMENT_____________________________ PLACEMENT AGENCY______________________________________

LIC 624A (7/99)

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Inside the segment EXPLAIN WHAT IMMEDIATE ACTION WAS, MEDICAL TREATMENT NECESSARY YES, NAME OF ATTENDING PHYSICIAN, NAME OF MORTICIAN, REPORT SUBMITTED BY, REPORT REVIEWEDAPPROVED BY, NAME AND TITLE, NAME AND TITLE, DATE, and DATE type in the information the application requests you to do.

death licensing online EXPLAIN WHAT IMMEDIATE ACTION WAS, MEDICAL TREATMENT NECESSARY  YES, NAME OF ATTENDING PHYSICIAN, NAME OF MORTICIAN, REPORT SUBMITTED BY, REPORT REVIEWEDAPPROVED BY, NAME AND TITLE, NAME AND TITLE, DATE, and DATE fields to complete

In the AGENCIESINDIVIDUALS NOTIFIED, LICENSING ADULTCHILD PROTECTIVE, LONG TERM CARE OMBUDSMAN, LAW ENFORCEMENT PLACEMENT AGENCY, and LIC A area, identify the vital particulars.

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