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STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION INSTRUCTIONS UNUSUAL INCIDENT/INJURY REPORT NOTIFY LICENSING AGENCY PLACEMENTAGENCY AND RESPONSIBLE PERSONS IF ANY BY NEXT WORKING DAY. SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE. RETAIN COPY OF REPORT IN CLIENT S FILE. NAME OF FACILITY FACILITY FILE NUMBER TELEPHONE NUMBER ADDRESS CITY STATE ZIP CLIENTS/RESIDENT.

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