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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION DEATH REPORT INSTRUCTIONS LICENSEE MUST REPORT THE DEATH OF A CLIENT OF ANY CAUSE REGARDLESS OF WHERE THE DEATH OCCURRED. O. B. TELEPHONE NUMBER SEX DATE OF ADMISSION PLACE OF DEATH DATE AND TIME 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 NAME OF ATTENDING PHYSICIAN IF YES GIVE NATURE OF TREATMENT NAME OF MORTICIAN NAME AND TITLE DATE REPORT SUBMITTED BY 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. 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 ADDRESS CITY STATE ZIP CLIENT S NAME D.

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Keywords relevant to Ca Death Report

  • Licensing
  • MORTICIAN
  • specify
  • contributing
  • occurrence
  • placement
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