101212(d)(1)(c) · 101212 Reporting Requirements(d)...a report shall be made to the Department by telephone or fax within the Department's next working day...(1) events shall include the follow:(C) any unusual incident...

Director states she will complete a declaration (LIC855) indicating that she has reviewed and understands the Reporting Requirement under CCR section 101212 and submit incident report via email and a copy to LPA. Based on interview and record review, the director did not report an unusal incident by telephone or fax which poses a potential health, safety and/or personal rights risk to persons in care. Warren Birks NAME OF LICENSING PROGRAM MANAGER: Peter Bishop NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/03/2026 I acknowledge receipt of this form and understand my appeal rights as explained and received.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.