Complaint Investigation Report

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

***An immediate civil penalty in the total amount of $100.00 has been issued for a lack of criminal

record clearance as required (See LIC 421BG).

Exit interview conducted. Plan of Corrections reviewed and developed with Administrator. Copy of report, LIC

9099-D, LIC421BG, and Appeal Rights discussed and provided to Administrator. Signature on form confirms