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STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING Date: REFERENCE REQUEST REPLY TO: Facility Name: Facility Number: Dear You have

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What is you have been given?

You have been given a document to file with the relevant authority.

Who is required to file you have been given?

The individual or entity specified in the document is required to file it.

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You can fill out the document by providing the requested information accurately and completely.

What is the purpose of you have been given?

The purpose of the document is to report specific information to the relevant authority.

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