LIC 624A: Death Report

The licensee must send the report to licensing: "Each licensee shall furnish to the licensing agency such reports as the Department may require" ^[2]. The form has a "Report submitted by" line and a "Report reviewed/approved by" line, each with a name, title and date ^[1].

The rule covers the "death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility" ^[2].

The form is a general Community Care Licensing Division form. Its header reads "California Department of Social Services, Community Care Licensing Division," it says "client," and it never names RCFEs ^[1].

The report goes to the licensing agency and to the person responsible for the resident ^[2]. The form's header also says to notify the licensing agency, the placement agency and responsible persons, "if any" ^[1]. The bottom of the form has lines to record who was told: licensing, Adult/Child Protective Services, the long-term care ombudsman, the parent, guardian or conservator, law enforcement, and the placement agency, each with a name and phone number ^[1].

Written report: seven days. Send it to licensing and to the person responsible for the resident within seven days of the death ^[2]. The rule says "seven days" and does not say business days ^[2].

The form's own header also says to notify the licensing agency, the placement agency and responsible persons "by next working day," and to submit the written report within 7 days of occurrence ^[1]. Title 22 § 87211 gives RCFEs the seven-day written report for a death ^[2].

Coroner's report. The form's cause-of-death line reads "if coroner report made, send copy within 30 days" ^[1]. The form does not say who receives the copy ^[1].

Suspected abuse of an elder or dependent adult is a separate clock. Title 22 § 87211(b) and (c) send you to Welfare and Institutions Code § 15630(b)(1) ^[2]. The SOC 341 page covers that report.

The form says "Retain copy of report in client's file" ^[1]. CDSS lists the Death Report, with the unusual incident/injury report, under "Residents Records," records that "must be kept in the facility complete and current, and readily available for review" ^[3].

Title 22 § 87506 requires a record for each resident, kept "in the facility or in a central administrative location readily available to facility staff and to licensing agency staff" ^[4]. Records are kept for a minimum of three years after service to the resident ends ^[4]. The section does not list death reports by name ^[4].

• The contents. § 87211(a)(1) lists what it must contain: the resident's name, age, sex and date of admission; the date and nature of the event; the attending physician's name, findings and treatment, if any; and what happened to the case ^[2].
• The form's fields ^[1]:
  • the facility name, file number and address
  • the client's name, date of birth, sex and date of admission
  • the date, time and place of death
  • the immediate cause of death
  • the conditions before or contributing to the death
  • the immediate action taken, including persons contacted
  • whether medical treatment was necessary and its nature
  • the names of the attending physician and the mortician
  Compare with § 87211(a)(1): the form asks for a date of birth, not an age, and has no field named "findings" or "disposition" ^[1].
• Who was notified. The bottom of the form asks who was told, with name and phone number ^[1].
• The dates. The date and time of death and the date of each signature are on the form ^[1]. The seven days run from the death ^[2].

From the CDSS forms list ^[5]:

• LIC 624 (4/99), Unusual Incident/Injury Report: the form CDSS lists beside LIC 624A in the RCFE records list ^[5][3].
• LIC 624B (8/08), Unusual Incident/Injury Report - Family Child Care Home: for family child care homes ^[7].
• LIC 624 LE (12/22), Law Enforcement Contact Report: for incidents where law enforcement contacts a child in a group home or similar children's program. Its check boxes list group homes, short-term residential therapeutic programs, community treatment facilities and similar programs, not RCFEs ^[8].