California Form LIC 624: Reporting Incidents, Deadlines, and Penalties

California Form LIC 624 is the Unusual Incident/Injury Report that community care facilities file with the California Department of Social Services whenever a reportable event occurs on site. The form is a free one-page PDF, but the obligations around it move on a clock: you phone your Community Care Licensing Division (CCLD) regional office by its next working day and deliver the completed, signed form within seven days of the incident. Miss either deadline and the facility is exposed to daily civil penalties.

Incidents That Require a Report

Title 22 of the California Code of Regulations sets the triggers. The exact section depends on your facility type, but the list of reportable events overlaps heavily across group homes, adult day programs, adult residential facilities, and transitional housing placement providers.

  • Death of any client, regardless of cause.
  • Any injury requiring medical treatment beyond basic first aid.
  • Use of an automated external defibrillator on a client, staff member, or visitor.
  • Suspected physical, sexual, or psychological abuse of a client.
  • Communicable disease outbreaks among residents or staff.
  • Poisonings, accidental or otherwise.
  • Any fire or explosion at the facility.
  • Catastrophes affecting safe occupancy, including major property damage and natural disasters.
  • Any unusual incident that threatens or could threaten a client’s physical or emotional well-being.

Depending on facility type, unauthorized absences, emergency relocations, and incidents involving law enforcement contact also require reporting.1Cornell Law Institute. California Code of Regulations Title 22 Section 86161 – Reporting Requirements The last trigger on the list is a catch-all, so when something sits on the line, file. A report that turns out to be minor costs nothing; a missed one is citable.

The Reporting Clock

Two deadlines run in parallel on every incident, and a third kicks in for serious abuse cases.

Initial notice by the next working day. As soon as a reportable event occurs, notify your assigned CCLD regional office by phone or in writing before the close of the agency’s next business day.2New York Codes, Rules and Regulations. 22 CA ADC Section 80061 – Reporting Requirements A Friday evening incident means a Monday morning call. The initial contact can be a phone call with the basic facts; it does not need to be the completed form.

Written report within seven days. The completed LIC 624 must reach the licensing agency within seven days of the incident. Mail, fax, or hand-deliver it to your regional office. If your placement agency is entitled to a copy under your facility type’s regulations, send it inside the same seven-day window.3New York Codes, Rules and Regulations. 22 CA ADC Section 72541 – Unusual Occurrences

Two hours for serious elder or dependent-adult abuse. Suspected physical abuse that results in serious bodily injury to an elder or dependent adult must be reported to the local ombudsman, the licensing agency, and local law enforcement within two hours. Physical abuse without serious bodily injury carries a 24-hour deadline to those same three entities.4Cornell Law Institute. California Code of Regulations Title 22 Section 82061 – Reporting Requirements These accelerated deadlines run alongside the standard LIC 624 process, not instead of it.

Getting the Form

Download Form LIC 624 directly from the CDSS forms portal at cdss.ca.gov/cdssweb/entres/forms/English/LIC624.PDF.5California Department of Social Services. Forms and Publications (I-L) The form is free. Keep printed copies on site so staff can start documenting the moment an incident happens, rather than hunting for the PDF while the clock runs.

Filling Out the Form

The form is one page, divided into a handful of sections. Accuracy matters because licensing analysts use the information to match the report to your facility file and decide whether to investigate.

Facility Identification

At the top, enter your facility’s registered name, facility file number, and telephone number. The facility file number is the one CCLD assigned when your license was issued; it appears on your license certificate and on correspondence from the department. A wrong file number can push the report into the wrong queue.

Client Information

Enter the affected client’s full name, age, sex, and date of admission.1Cornell Law Institute. California Code of Regulations Title 22 Section 86161 – Reporting Requirements If more than one client was involved, complete a separate form for each. The admission date gives analysts context: a pattern of incidents just after admission reads differently from one involving a long-term resident.

Incident Details

Record the exact date and time. Then write a factual, objective description: what happened, who was present, and what staff did immediately. Stick to observable facts. If a client fell and hit their head, write that, not “the client appeared to have a seizure.” Avoid speculation about cause, blame, or medical diagnoses you are not qualified to make. If you called 911, include the time of the call and when paramedics arrived.

The narrative should also document immediate corrective actions: moving the client to safety, administering first aid, securing a hazard, or increasing supervision. Analysts want to see an appropriate response, not just a logged event.

External Notifications

Record every outside notification: law enforcement, local health department, protective services, and any placement agency involved in the client’s care. Include the name and contact information of each person you spoke with, plus the date and time of each call. If law enforcement responded, note the officer’s name and badge number.

You also have to document when the client’s authorized representative or family was informed.1Cornell Law Institute. California Code of Regulations Title 22 Section 86161 – Reporting Requirements If there is no authorized representative, say so on the form rather than leaving the field blank.

Signature and Date

The person completing the report signs and dates it. Keep the original for the client’s file and send a copy to the licensing agency. An unsigned form is an incomplete form, and during an unannounced inspection the analyst will check whether the copy in the client’s file is signed and dated.

Where to Send It

The completed form goes to the CCLD regional office that handles your facility. Which office that is depends on your license type and location, and CDSS publishes separate regional directories for Adult and Senior Care, Child Care, and Children’s Residential programs. Each directory lists office addresses, phone numbers, and fax numbers.6California Department of Social Services. Community Care Licensing If you are not sure which office covers you, call the CCLD complaint and information hotline at 1-844-538-8766.7California Department of Social Services. Community Care Licensing Complaint Form

Keeping a Copy in the Client File

The instructions on the form itself tell you to retain a copy in the affected client’s file. Keep the signed, dated copy in the client’s permanent record at the facility. During unannounced inspections, analysts routinely check whether incident reports are present in client files and whether they match the copies on file at the regional office. A missing or unsigned copy in the client file can draw a deficiency citation even when the regional office received its copy on time.

What Late or Missing Reports Cost

Failing to file, or filing late, exposes the facility to escalating civil penalties under California Health and Safety Code Section 1548. The structure is tiered.

  • Standard violations: $100 per day for each violation the facility fails to correct after being given time to do so.
  • Repeat standard violations: an immediate $250 per violation, plus $100 per day until corrected.
  • Serious violations: an immediate $500 per violation, plus $100 per day. This tier covers violations that result in injury or illness to a person in care, fire clearance problems, lack of required supervision, accessible firearms, and refusing entry to licensing inspectors.
  • Repeat serious violations: an immediate $1,000 per violation, plus $100 per day.
  • Violation resulting in death: $15,000 for adult residential facilities, social rehabilitation facilities, community crisis homes, and similar settings.
  • Physical abuse or serious bodily injury: $10,000 for the same facility types.

These penalties come on top of any other licensing action the department takes, including temporary suspension or revocation.8California Legislative Information. California Health and Safety Code HSC 1548 The daily charges add up: a $500 serious violation that goes 30 days without correction becomes $3,500. Penalty assessments for incidents involving death or serious bodily injury require approval from the CCLD program administrator, but that is an internal check, not a safety net. Report on time, sign the form, and keep the file copy clean.