Transcription of IDENTIFICATION AND EMERGENCY INFORMATION
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IDENTIFICATION AND EMERGENCY INFORMATION
STATE OF CALIFORNIAHEALTH AND HUMAN services AGENCYCALIFORNIA department OF social SERVICESCOMMUNITY CARE LICENSING DIVISIONIDENTIFICATION ANDEMERGENCY INFORMATIONThis INFORMATION is required under the H & S Code and the regulationsof the department to be maintained on every person admitted to acommunity care facility, to be readily available to the person in charge,but not accessible to unauthorized persons. All INFORMATION must bekept current. See other side for additional INFORMATION required forresidential facilities for ALL FACILITIES [EXCEPT CHILD CARE CENTER/FAMILY CHILD CARE HOME COMPLETES LIC 700]PERSON(S) RESPONSIBLE FOR FINANCIAL AFFAIRS, PAYMENT FOR CARE, LEGAL GUARDIAN, IF ANYOTHER PERSONS TO BE NOTIFIED IN EMERGENCYEMERGENCY HOSPITALIZATION PLANOTHER REQUIRED INFORMATION1. NAME OF CLIENT OR CHILD2. RESPONSIBLE PERSON OR PLACEMENT AGENCY3. NAME OF NEAREST RELATIVE (OPTIONAL)4. DATE ADMITTED TO FACILITY5. DATE LEFT6.
state of california health and human services agency california department of social services community care licensing division identification and
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