STATEMENT ACKNOWLEDGING REQUIREMENT TO REPORT …
instance of abuse (physical abuse, sexual abuse, financial abuse, abduction, neglect (self-neglect), isolation, and abandonment) involving an elder or dependent adult. Reporting shall be completed as follows: • If the abuse occurred in a LongTerm Care (LTC) facility (as defined in …
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cdss.ca.govJ. WRITTEN REPORT Enter information about the agencies receiving this report. If the abuse occurred in a LTC facility and resulted in Serious Bodily Injury*, please refer to “Reporting Responsibilities and Time Frames” in the General Instructions. Do not submit report to California Department of Social Services Adult Programs Division.
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