Get Ca Lic 809 2004

The CA LIC 809 is an essential facility evaluation report form used by the California Department of Social Services. This guide provides user-friendly, step-by-step instructions to assist you in accurately completing the form online.

Follow the steps to fill out the CA LIC 809 effectively.

1. Click the ‘Get Form’ button to access the CA LIC 809 form and open it in an editor.
2. Begin by filling in the facility name, director's name, facility number, address, telephone number, and capacity in the designated fields. Ensure this information is accurate, as it is critical for identification purposes.
3. Indicate the type of visit you are reporting by checking the appropriate box. Options include office visit, prelicensing, annual management, follow-up, Type A deficiencies, or Type B deficiencies.
4. Record the date, time the visit began, and whether the visit was announced or unannounced. This information is crucial for documentation.
5. In the deficiency information section, detail any deficiencies observed during the visit. Make sure to reference the specific California regulations that relate to the deficiencies while providing comments and necessary notes.
6. Fill out the civil penalty information, noting if any penalties were assessed or cleared. If no deficiencies were cited, check the appropriate box.
7. Outline the plan of corrections (POCs) in the specified area. Specify how you will address each deficiency and include due dates for corrections.
8. Once all sections are completed, ensure all information is reviewed for accuracy. You may want to save changes regularly.

Complete your CA LIC 809 form online today for a streamlined experience.