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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY

CONFIDENTIAL REPORT -

NOT SUBJECT TO PUBLIC DISCLOSURE

REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

DATE COMPLETED:

TO BE COMPLETED BY REPORTING PARTY. PLEASE PRINT OR TYPE. SEE GENERAL INSTRUCTIONS.

A. VICTIM ■ Check box if victim consents to disclosure of information [Ombudsman use only - WIC 15636(a)]

*NAME (LAST NAME FIRST)

*AGE

DATE OF BIRTH SSN

GENDER

■ M ■ F

ETHNICITY

LANGUAGE (✔ CHECK ONE)

■NON-VERBAL ■ ENGLISH

■OTHER (SPECIFY)

*ADDRESS (IF FACILITY, INCLUDE NAME AND NOTIFY OMBUDSMAN)	*CITY	*ZIP CODE	*TELEPHONE
			(	)

*PRESENT LOCATION (IF DIFFERENT FROM ABOVE)	*CITY	*ZIP CODE	*TELEPHONE
			(	)

■ ELDERLY (65+)

■ DEVELOPMENTALLY DISABLED

■ MENTALLY ILL/DISABLED

■ PHYSICALLY DISABLED

■ UNKNOWN/OTHER

■ LIVES ALONE

■ LIVES WITH OTHERS

B. SUSPECTED ABUSER

✔ Check if ■ Self-Neglect

NAME OF SUSPECTED ABUSER

■ CARE CUSTODIAN (type)______________________________

■ PARENT

■ SON/DAUGHTER

■ OTHER_________________

■ HEALTH PRACTITIONER (type) _________________________

■ SPOUSE

■ OTHER RELATION_____________________________

ADDRESS

*ZIP CODE

TELEPHONE

GENDER

ETHNICITY

AGE

D.O.B.

HEIGHT

WEIGHT

EYES

HAIR

(

)

■ M ■ F

C. REPORTING PARTY: Check appropriate box if reporting party waives confidentiality to:

■ ✔ All

■ ✔ All but victim

■ ✔ All but perpetrator

*NAME (PRINT)

SIGNATURE

OCCUPATION

AGENCY/NAME OF BUSINESS

RELATION TO VICTIM/HOW KNOWS OF ABUSE

(STREET)

(CITY)

(ZIP CODE)

(E-MAIL ADDRESS)

TELEPHONE

( )

D.INCIDENT INFORMATION - Address where incident occurred:

*DATE/TIME OF INCIDENT(S)

PLACE OF INCIDENT (✔ CHECK ONE)
■ OWN HOME	■ COMMUNITY CARE FACILITY	■ HOSPITAL/ACUTE CARE HOSPITAL
■ HOME OF ANOTHER	■ NURSING FACILITY/SWING BED	■ OTHER (Specify)

E.REPORTED TYPES OF ABUSE (✔ CHECK ALL THAT APPLY).

1. PERPETRATED BY OTHERS (WIC 15610.07 & 15610.63)						2. SELF-NEGLECT (WIC 15610.57(b)(5))
a. PHYSICAL							■ PHYSICAL CARE (e.g., personal hygiene, food, clothing, shelter)
■	ASSAULT/BATTERY	b.	■ NEGLECT	f.	■ ABDUCTION	a.
						b.	■ MEDICAL CARE (e.g., physical and mental health needs)
■	CONSTRAINT OR DEPRIVATION	c.	■ FINANCIAL	g.	■ OTHER (Non-Mandated: e.g.,
						c.	■ HEALTH and SAFETY HAZARDS
■	SEXUAL ASSAULT	d.	■ ABANDONMENT		deprivation of goods and
						d.	■ MALNUTRITION/DEHYDRATION
■	CHEMICAL RESTRAINT	e.	■ ISOLATION		services: psychological/mental)
						e.	■ OTHER (Non-Mandated e.g., financial)
■	OVER OR UNDER MEDICATION

ABUSE RESULTED IN (✔ CHECK ALL THAT APPLY) ■ NO PHYSICAL INJURY ■ MINOR MEDICAL CARE							■ HOSPITALIZATION ■ CARE PROVIDER REQUIRED
			■ DEATH	■ MENTAL SUFFERING ■ OTHER (SPECIFY)				■ UNKNOWN

F.REPORTER’S OBSERVATIONS, BELIEFS, AND STATEMENTS BY VICTIM IF AVAILABLE. DOES ALLEGED PERPETRATOR STILL HAVE ACCESS TO THE VICTIM? PROVIDE ANY KNOWN TIME FRAME (2 days, 1 week, ongoing, etc.). LIST ANY POTENTIAL DANGER FOR INVESTIGATOR (animals, weapons, communicable diseases, etc.). ■ ✔CHECK IF MEDICAL, FINANCIAL, PHOTOGRAPHS OR

OTHER SUPPLEMENTAL INFORMATION IS ATTACHED.

G. TARGETED ACCOUNT

ACCOUNT NUMBER (LAST 4 DIGITS):	TYPE OF ACCOUNT: ■ DEPOSIT ■ CREDIT ■ OTHER		■ YES	■ NO
	TYPE OF ACCOUNT: ■ DEPOSIT ■ CREDIT ■ OTHER	TRUST ACCOUNT:	■ YES	■ NO

POWER OF ATTORNEY: ■ YES ■ NO	DIRECT DEPOSIT: ■ YES ■ NO	OTHER ACCOUNTS:	■ YES	■ NO

H. OTHER PERSON BELIEVED TO HAVE KNOWLEDGE OF ABUSE. (family, significant others, neighbors, medical providers and agencies involved, etc.)

NAME	ADDRESS

TELEPHONE NO.

( )

RELATIONSHIP

I.FAMILY MEMBER OR OTHER PERSON RESPONSIBLE FOR VICTIM’S CARE. (If unknown, list contact person).

*NAME

*ADDRESS

	IF CONTACT PERSON ONLY ✔ CHECK ■		*RELATIONSHIP
*CITY		*ZIP CODE	*TELEPHONE

			(	)

J. TELEPHONE REPORT MADE TO: ■ Local APS ■ Local Law Enforcement ■ Local Ombudsman ■ Calif. Dept. of Mental Health ■ Calif. Dept. of Developmental Services

NAME OF OFFICIAL CONTACTED BY PHONE

*TELEPHONE

( )

DATE/TIME

K.WRITTEN REPORT Enter information about the agency receiving this report. Do not submit report to California Department of Social Services Adult Programs Bureau.

AGENCY NAME

ADDRESS OR FAX #

■ Date Mailed:

■ Date Faxed:

L.	RECEIVING AGENCY USE ONLY ■ Telephone Report		■ Written Report
1.	Report Received by:			Date/Time:

2.	Assigned ■ Immediate Response	■ Ten-day Response ■ No Initial Face-To-Face Required ■ Not APS ■ Not Ombudsman

	Approved by:		Assigned to (optional):

3.Cross-Reported to: ■ CDHS, Licensing & Cert.; ■ CDSS-CCL; ■ CDA Ombudsman; ■ Bureau of Medi-Cal Fraud & Elder Abuse; ■ Mental Health; ■ Law Enforcement;

■ Professional Board; ■ Developmental Services; ■ APS; ■ Other (Specify)	Date of Cross-Report:

4. APS/Ombudsman/Law Enforcement Case File Number:_____________________________________

SOC 341 (12/06)

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE

GENERAL INSTRUCTIONS

PURPOSE OF FORM

This form, as adopted by the California Department of Social Services (CDSS), is required under Welfare and Institutions Code (WIC) Sections 15630 and 15658(a)(1). This form documents the information given by the reporting party on the suspected incident of abuse of an elder or dependent adult. "Elder," means any person residing in this state who is 65 years of age or older (WIC Section 15610.27). "Dependent Adult," means any person residing in this state, between the ages of 18 and 64, who has physical or mental limitations that restrict his or her ability to carry out normal activities or to protect his or her rights including, but not limited to, persons who have physical or developmental disabilities or whose physical or mental abilities have diminished because of age (WIC Section 15610.23). Dependent adult includes any person between the ages of 18 and 64 who is admitted as an inpatient to a 24-hour health facility (defined in the Health and Safety Code Sections 1250, 1250.2, and 1250.3).

COMPLETION OF THE FORM

1.This form may be used by the receiving agency to record information through a telephone report of suspected dependent adult/elder abuse. Complete items with an asterisk (*) when a telephone report of suspected abuse is received as required by statute and the California Department of Social Services.

2.If any item of information is unknown, enter "unknown.”

3.Item A: Check box to indicate if the victim waives confidentiality.

4.Item C: Check box if the reporting party waives confidentiality. Please note that mandated reporters are required to disclose their names, however, non-mandated reporters may report anonymously.

REPORTING RESPONSIBILITIES

Mandated reporters (see definition below under "Reporting Party Definitions") shall complete this form for each report of a known or suspected instance of abuse (physical abuse, sexual abuse, financial abuse, abduction, neglect, (self-neglect), isolation, and abandonment (see definitions in WIC Section 15610) involving an elder or a dependent adult. The original of this report shall be submitted within two

(2) working days of making the telephone report to the responsible agency as identified below:

●The county Adult Protective Services (APS) agency or the local law enforcement agency (if abuse occurred in a private residence, apartment, hotel or motel, or homeless shelter).

●Long-Term Care Ombudsman (LTCO) program or the local law enforcement agency (if abuse occurred in a nursing home, adult residential facility, adult day program, residential care facility for the elderly, or adult day health care center).

●The California Department of Mental Health or the local law enforcement agency (if abuse occurred in Metropolitan State Hospital, Atascadero State Hospital, Napa State Hospital, or Patton State Hospital).

●The California Department of Developmental Services or the local law enforcement agency (if abuse occurred in Sonoma Developmental Center, Lanterman Developmental Center, Porterville Developmental Center, Fairview Developmental Center, or Agnews Developmental Center).

WHAT TO REPORT

Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment has observed, suspects, or has knowledge of an incident that reasonably appears to be physical abuse (including sexual abuse), abandonment, isolation, financial abuse, abduction, or neglect (including self-neglect), or is told by an elder or a dependent adult that he or she has experienced behavior constituting physical abuse, abandonment, isolation, financial abuse, abduction, or neglect, shall report the known or suspected instance of abuse by telephone immediately or as soon as practicably possible, and by written report sent within two working days to the appropriate agency.

REPORTING PARTY DEFINITIONS

Mandated Reporters (WIC) "15630 (a) Any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent adult, whether or not that person receives compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter."

Care Custodian (WIC) "15610.17 'Care custodian' means an administrator or an employee of any of the following public or private facilities or agencies, or persons providing care or services for elders or dependent adults, including members of the support staff and maintenance staff:

(a)Twenty-four-hour health facilities, as defined in Sections 1250, 1250.2, and 1250.3 of the Health and Safety Code. (b) Clinics. (c) Home health agencies. (d) Agencies providing publicly funded in-home supportive services, nutrition services, or other home and community-based support services. (e) Adult day health care centers and adult day care. (f) Secondary schools that serve 18- to 22-year-old dependent adults and postsecondary educational institutions that serve dependent adults or elders. (g) Independent living centers. (h) Camps. (i) Alzheimer's Disease Day Care Resource Centers. (j) Community care facilities, as defined in Section 1502 of the Health and Safety Code, and residential care facilities for the elderly, as defined in Section 1569.2 of the Health and Safety Code. (k) Respite care facilities. (l) Foster homes. (m) Vocational rehabilitation facilities and work activity centers. (n) Designated area agencies on aging. (o) Regional centers for persons with developmental disabilities. (p) State Department of Social Services and State Department of Health Services licensing divisions. (q) County welfare departments. (r) Offices of patients' rights advocates and clients' rights advocates, including attorneys. (s) The Office of the State Long-Term Care Ombudsman. (t) Offices of public conservators, public guardians, and court investigators. (u) Any protection or advocacy

SOC 341 (12/06) GENERAL INSTRUCTIONS

INSTRUCTIONS - PAGE 1 OF 3

GENERAL INSTRUCTIONS (Continued)

agency or entity that is designated by the Governor to fulfill the requirements and assurances of the following: (1) The federal Developmental Disabilities Assistance and Bill of Rights Act of 2000, contained in Chapter 144 (commencing with Section 15001) of Title 42 of the United States Code, for protection and advocacy of the rights of persons with developmental disabilities. (2) The Protection and Advocacy for the Mentally Ill Individuals Act of 1986, as amended, contained in Chapter 114 (commencing with Section 10801) of Title 42 of the United States Code, for the protection and advocacy of the rights of persons with mental illness. (v) Humane societies and animal control agencies. (w) Fire departments. (x) Offices of environmental health and building code enforcement. (y) Any other protective, public, sectarian, mental health, or private assistance or advocacy agency or person providing health services or social services to elders or dependent adults."

Health Practitioner (WIC) "15610.37 'Health practitioner' means a physician and surgeon, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropractor, licensed nurse, dental hygienist, licensed clinical social worker or associate clinical social worker, marriage, family, and child counselor, or any other person who is currently licensed under Division 2 (commencing with Section 500) of the Business and Professions Code, any emergency medical technician I or II, paramedic, or person certified pursuant to Division 2.5 (commencing with Section 1797) of the Health and Safety Code, a psychological assistant registered pursuant to Section 2913 of the Business and Professions Code, a marriage, family, and child counselor trainee, as defined in subdivision (c) of Section 4980.03 of the Business and Professions Code, or an unlicensed marriage, family, and child counselor intern registered under Section 4980.44 of the Business and Professions Code, state or county public health or social service employee who treats an elder or a dependent adult for any condition, or a coroner."

Officers and Employees of Financial Institutions (WIC) “15630.1. (a) As used in this section, “mandated reporter of suspected financial abuse of an elder or dependent adult” means all officers and employees of financial institutions. (b) As used in this section, the term “financial institution” means any of the following: (1) A depository institution, as defined in Section 3(c) of the Federal Deposit Insurance Act (12 U.S.C. Sec. 1813(c)). (2) An institution-affiliated party, as defined in Section 3(u) of the Federal Deposit Insurance Act (12 U.S.C. Sec. 1813(u)). (3) A federal credit union or state credit union, as defined in Section 101 of the Federal Credit Union Act (12 U.S.C. Sec. 1752), including, but not limited to, an institution-affiliated party of a credit union, as defined in Section 206(r) of the Federal Credit Union Act (12 U.S.C. Sec. 1786 (r)). (c)As used in this section, “financial abuse” has the same meaning as in Section 15610.30. (d)(1)Any mandated reporter of suspected financial abuse of an elder or dependent adult who has direct contact with the elder or dependent adult or who reviews or approves the elder or dependent adult’s financial documents, records, or transactions, in connection with providing financial services with respect to an elder or dependent adult, and who, within the scope of his or her employment or professional practice, has observed or has knowledge of an incident that is directly related to the transaction or matter that is within that scope of employment or professional practice, that reasonably appears to be financial abuse, or who reasonably suspects that abuse, based solely on the information before him or her at the time of reviewing or approving the document, records, or transaction in the case of mandated reporters who do not have direct contact with the elder or dependent adult, shall report the known or suspected instance of financial abuse by telephone immediately, or as soon as practicably possible, and by written report sent within two working days to the local adult protective services agency or the local law enforcement agency.”

MULTIPLE REPORTERS

When two or more mandated reporters are jointly knowledgeable of a suspected instance of abuse of a dependent adult or elder, and when there is agreement among them, the telephone report may be made by one member of the group. Also, a single written report may be completed by that member of the group. Any person of that group, who believes the report was not submitted, shall submit the report.

IDENTITY OF THE REPORTER

The identity of all persons who report under WIC Chapter 11 shall be confidential and disclosed only among APS agencies, local law enforcement agencies, LTCO coordinators, California State Attorney General Bureau of Medi-Cal Fraud and Elder Abuse, licensing agencies or their counsel, Department of Consumer Affairs Investigators (who investigate elder and dependent adult abuse), the county District Attorney, the Probate Court, and the Public Guardian. Confidentiality may be waived by the reporter or by court order.

FAILURE TO REPORT

Failure to report by mandated reporters (as defined under “Reporting Party Definitions”) any suspected incidents of physical abuse (including sexual abuse), abandonment, isolation, financial abuse, abduction, or neglect (including self-neglect) of an elder or a dependent adult is a misdemeanor, punishable by not more than six months in the county jail, or by a fine of not more than $1,000, or by both imprisonment and fine. Any mandated reporter who willfully fails to report abuse of an elder or a dependent adult, where the abuse results in death or great bodily injury, may be punished by up to one year in the county jail, or by a fine of up to $5,000, or by both imprisonment and fine.

Officers or employees of financial institutions (defined under “Reporting Party Definitions”) are mandated reporters of financial abuse (effective January 1, 2007). These mandated reporters who fail to report financial abuse of an elder or dependent adult are subject to a civil penalty not exceeding $1,000. Individuals who willfully fail to report financial abuse of an elder or dependent adult are subject to a civil penalty not exceeding $5,000. These civil penalties shall be paid by the financial institution, which is the employer of the mandated reporter to the party bringing the action.

SOC 341 (12/06) GENERAL INSTRUCTIONS

INSTRUCTIONS - PAGE 2 OF 3

GENERAL INSTRUCTIONS (Continued)

EXCEPTIONS TO REPORTING

Per WIC Section 15630(b)(3)(A), a mandated reporter who is a physician and surgeon, a registered nurse, or a psychotherapist, as defined in Section 1010 of the Evidence Code, shall not be required to report a suspected incident of abuse where all of the following conditions exist:

(1)The mandated reporter has been told by an elder or a dependent adult that he or she has experienced behavior constituting physical abuse (including sexual abuse), abandonment, isolation, financial abuse, abduction, or neglect (including self-neglect).

(2)The mandated reporter is not aware of any independent evidence that corroborates the statement that the abuse has occurred.

(3)The elder or the dependent adult has been diagnosed with a mental illness or dementia, or is the subject of a court-ordered conservatorship because of a mental illness or dementia.

(4)In the exercise of clinical judgment, the physician and surgeon, the registered nurse, or the psychotherapist, as defined in Section 1010 of the Evidence Code, reasonably believes that the abuse did not occur.

Per WIC Section 15630(b)(4)(A), in a long-term care facility, a mandated reporter who the California Department of Health Services determines, upon approval by the Bureau of Medi-Cal Fraud and the Office of the State Long-Term Care Ombudsman (OSLTCO), has access to plans of care and has the training and experience to determine whether all the conditions specified below have been met, shall not be required to report the suspected incident of abuse:

(1)The mandated reporter is aware that there is a proper plan of care.

(2)The mandated reporter is aware that the plan of care was properly provided and executed.

(3)A physical, mental, or medical injury occurred as a result of care pursuant to clause (1) or (2).

(4)The mandated reporter reasonably believes that the injury was not the result of abuse.

DISTRIBUTION OF SOC 341 COPIES

Mandated reporter: After making the telephone report to the appropriate agency, the reporter shall send the original and one copy to the agency; keep one copy for the reporter’s file.

Receiving agency: Place the original copy in the case file. Send a copy to a cross-reporting agency, if applicable.

DO NOT SEND A COPY TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES ADULT PROGRAMS BUREAU.

SOC 341 (12/06) GENERAL INSTRUCTIONS

INSTRUCTIONS - PAGE 3 OF 3

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