FACILITY NAME DATE FACILITY ADDRESS CITY STATE ZIP CODE OPERATOR / Residential Care Facility / Unlicensed Facility / Community Care Facility / /
Organization
Child Care Center / California Department of Social Services / HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES CIVIL PENALTY ASSESSMENT / Regional Office / /
Position
cashier / ANALYST NAME / Licensing Program Analyst / ANALYST SIGNATURE / /
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES CIVIL PENALTY ASSESSMENT (Unlicensed Facility) FACILITY NAME