Form LIC 9187 Child Care Client Death Report - California

Form LIC9187 or the "Child Care Client Death Report" is a form issued by the California Department of Social Services.

Download a fillable PDF version of the Form LIC9187 down below or find it on the California Department of Social Services Forms website.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FOR PUBLIC FILE
CHILD CARE CLIENT DEATH REPORT
NOTE: Effective July 1, 2000, it is the policy of the Community Care
Licensing Division to place in the Licensing Offices’ facility public file,
information regarding the death of any child in a child care setting. Any
instance of a death of a child in care results in a licensing visit. The results
of the initial and subsequent visit may be documented in the public section
of the file. Additional information may be available on other forms in this file.
LICENSING OFFICE INFORMATION
__________________________________________________________
Responsible Licensing Office
FACILITY INFORMATION
Facility Name __________________________________________________________________________________
Facility Number ________________________________________________________________________________
Census at Time of Death__________________________________________________________________________
CLIENT INFORMATION
Sex of Client __________________________________________________________________________________
Client’s Age ____________________________________________________________________________________
Date of Death __________________________________________________________________________________
Place of Death__________________________________________________________________________________
Cause of Death ________________________________________________________________________________
This form is placed in the public file, as soon as the cause of death is known.
LIC 9187 (7/00)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FOR PUBLIC FILE
CHILD CARE CLIENT DEATH REPORT
NOTE: Effective July 1, 2000, it is the policy of the Community Care
Licensing Division to place in the Licensing Offices’ facility public file,
information regarding the death of any child in a child care setting. Any
instance of a death of a child in care results in a licensing visit. The results
of the initial and subsequent visit may be documented in the public section
of the file. Additional information may be available on other forms in this file.
LICENSING OFFICE INFORMATION
__________________________________________________________
Responsible Licensing Office
FACILITY INFORMATION
Facility Name __________________________________________________________________________________
Facility Number ________________________________________________________________________________
Census at Time of Death__________________________________________________________________________
CLIENT INFORMATION
Sex of Client __________________________________________________________________________________
Client’s Age ____________________________________________________________________________________
Date of Death __________________________________________________________________________________
Place of Death__________________________________________________________________________________
Cause of Death ________________________________________________________________________________
This form is placed in the public file, as soon as the cause of death is known.
LIC 9187 (7/00)

Download Form LIC 9187 Child Care Client Death Report - California

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