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LIC 809: Facility Evaluation Report
By Sevana Care · Checked against cdss.ca.gov and Title 22 on
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Get the checklist- When it is due
- Each deficiency has its own date in the "POC Due Date" column [1].Title 22 § 87756 says that date "shall not be more than 30 calendar days following service of the notice of deficiency", unless the analyst finds it cannot be done in 30 [5]. "Unless otherwise specified in the plan of correction, the residential care facility for the elderly shall remedy the deficiencies within 10 days of the notification" (HSC § 1569.33) [6].
- Who fills it out
- The analyst writes it before leaving the home [3][5].The facility representative signs beside the line "I understand my licensing appeal rights as explained on the back of this form" [1].
- Where it is kept
- The form prints an agency copy and a facility copy [1].The report is public: "This report is available for public review" [1]. The LIC 9242 entrance checklist asks for "Licensing reports (last 12 months)" at the next inspection [15].
- How long to keep
- Post it.HSC § 1569.38 says a home "shall place in a conspicuous place copies of all licensing reports issued by the department within the preceding 12 months", plus the reports from the most recent annual visit [12].
LIC 809 is the California Department of Social Services (CDSS) Facility Evaluation Report. The Licensing Program Analyst (LPA) uses it to write up a visit [3]. You get the facility copy [1][11]. Each deficiency sits on the left with the rule it breaks, and your plan of correction and its due date sit across from it [1]. CDSS uses the same form for annual visits in every type of facility its Community Care Licensing Division licenses, RCFEs included [4]. The back of the form explains Type A and Type B deficiencies, plans of correction, penalties and how to appeal [1].
Which homes get it
CDSS's Evaluator Manual, the manual its analysts work from, says: "The Licensing Report LIC 809 will be used for all Required Annual Visits and Random Sample Visits." It says to "Apply the following criteria for all facility categories" [4]. The same manual has a part on using it at child care centers [3].
The form itself names RCFEs. Its email paragraph says RCFEs "are required to provide and maintain an active email address of record with the licensing agency" [1].
The analyst uses it for visits that are not about a complaint [3]:
- pre-licensing and post-licensing inspections
- required routine inspections, such as annual ones
- random annual inspections
- collateral visits at a licensed facility
- case management visits
- plan of correction visits
- office visits
A complaint visit is written up on LIC 9099, the Complaint Investigation Report. That form says "USE LIC 809 FOR ALL CITATIONS" [13].
For RCFEs, Title 22 § 87756(e) lists what the written notice of deficiency must include [5]:
- "A reference to the statute or regulation upon which the deficiency is premised."
- a factual description of how the home failed to comply, and where in the home
- the plan for correcting each deficiency, made at the exit meeting
- "A date by which each deficiency shall be corrected."
- the penalty and the date it starts if the deficiency is not corrected by the due date
- the address and phone number of the licensing office that reviews notices for your area
Type A, Type B and the rule cited
The back of the form defines both types [1]:
- Type A: "violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care."
- Type B: "violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care."
The state's facility search site calls the same two kinds Type A and Type B citations. Our inspections page quotes its glossary and shows how often small homes get each.
Read the section number next to each deficiency first. It tells you which rule the analyst found you out of line with. Our Title 22 page lists the RCFE sections by Article.
Advisory notes go on their own form. LIC 9102TV is headed "THIS IS NOT A NOTICE OF DEFICIENCY" and covers violations "that do not pose a health, safety or personal rights risk" [14].
Writing the plan of correction
Title 22 says the analyst meets with you before the visit ends: "At the meeting, a plan for correcting each deficiency shall be developed and included in the notice of deficiency" [5]. LIC 9058 lists "The right, at the time of the visit, to determine and develop a plan of correction for deficiencies cited" [11].
The form asks for "a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections" [1].
The Evaluator Manual says each plan is "developed jointly by the facility representative and the LPA" and must "contain corrective actions which are verifiable and measurable" [3]. It gives two pairs of examples [3]:
Accepted
"All staff will be required to attend personal rights training within the next 14 days."
Measurable [3]
Accepted
"The window will be fixed and photographs of the repairs submitted to the licensing office by the appointed due date."
Verifiable [3]
It also says: "It is not acceptable to simply state “all corrections will be made in 30 days” on the report. Each correction must occur as soon as reasonably possible" [3]. Each plan "is subject to Department approval" [3].
If you need more time to write it, the manual says you may sometimes "submit a written POC by a specific date agreed upon" with the analyst, noted on the report [3].
More time to correct. The form says a licensee with "problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date" [1]. The manual says a request is considered only if it comes "prior to the POC due date" or "within 10 working days of the receipt of the POC notice", and an approved extension is "for up to 30 days" [3]. For a Type A deficiency it comes with a condition: "The facility must resolve the immediate risk situation" first [3].
Proving each correction
The form says you are "responsible for completing all corrections and promptly notifying the licensing agency of corrections." It advises you "to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given" [1].
CDSS's Proof of Correction(s) form, LIC 9098, "shall be used in conjunction with the Licensing Report (LIC 809)" [8]. For each deficiency you tick the kind of proof: "PICTURE", "RECEIPT", "PHOTOCOPY", "CERTIFICATION" or "OTHER". You sign it "under penalty of perjury". You send it back "by the plan of correction date for each of the deficiencies" [8].
The manual lists other ways the plan can say proof will reach the analyst: a plan of correction inspection, an office meeting, mail or delivery, drop-off, or email [3].
Title 22 § 87759(a): "A follow-up visit shall be conducted within 10 working days following the latest date of correction specified in the notice of deficiency, unless the licensee has demonstrated that the deficiency was corrected as required in the notice of deficiency" [7].
If a correction date is missed
Page 1 of the form says: "Failure to correct the above cited deficiency(ies) on or before the Plan of Correction (POC) due date may result in a civil penalty assessment" [1].
- A daily penalty. HSC § 1569.49 sets "one hundred dollars ($100) per day for each violation of this chapter if the facility fails to correct a deficiency after being provided a specified length of time to correct that deficiency" [9]. It stops "as of the day the department received" evidence it accepts, or on an earlier date if the department can verify the deficiency was corrected before then [9].
- A $200 fee. The state charges a $200 plan of correction fee when a licensee does not carry out a plan of correction by its date [10].
- When you pay. The form says penalties are paid "when administrative appeals have been exhausted" [1].
Title 22 § 87759(b) says that if the follow-up visit shows a deficiency was not corrected by its date, "the evaluator shall issue a notice of penalty" [7].
Appealing a deficiency
The form says you may "discuss any disagreement in this report with the licensing agency" and "request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/or civil penalty" [1]. LIC 9058 lists "The right to use licensing reports as a means to agree or disagree with cited deficiencies" [11].
For a deficiency, or a penalty other than one for a death, serious injury or physical abuse, the steps in LIC 9058 and HSC § 1569.49(j) are [9][11]:
- Regional Manager. A written request, sent within 15 business days of getting the report or the penalty notice, with "all available supporting documentation" [1][9]. LIC 9058 says to file it "with Regional Office of jurisdiction over the facility" [11]. You hear back "within 60 business days of the date when all necessary information has been provided" [9].
- Program Administrator. Filed "within 15 business days of receipt of notice of the regional manager’s decision". That decision "is considered final" [9].
Penalties for a death, serious bodily injury or physical abuse go to the Deputy Director, then an Administrative Law Judge [11].
Other forms you may see with it
- LIC 809C and LIC 809D. Pages of the electronic report: LIC 809C for "overflow narrative" and LIC 809D for "deficiencies/Plan of Correction" [3]. Neither is on CDSS's forms list [2].
- LIC 9099, the Complaint Investigation Report [13].
- LIC 9098, Proof of Correction(s) [8].
- LIC 9058, Applicant/Licensee Rights, which the form names for appeals [1][11].
- LIC 9102TV and LIC 9102TA, advisory notes [14].
- LIC 812, Detail Supportive Information, the analyst's backup notes. It is "generally not public information" [16].
Questions
Does signing the LIC 809 mean I agree with it?
The form does not say. The signature line reads "I understand my licensing appeal rights as explained on the back of this form" [1]. LIC 9058 lists "The right to use licensing reports as a means to agree or disagree with cited deficiencies" [11].
Is my LIC 809 public?
Yes. The form says "California law requires a public report of each licensing visit/inspection" and "This report is available for public review" [1]. The law makes inspection reports, lists of deficiencies and plans of correction open to public inspection [6].
Where do I find LIC 809D?
It is a page of the report printed from CDSS's system, not a separate form. The Evaluator Manual calls it the page "for writing up citations of Type A and Type B violations" [3]. CDSS's forms list has LIC 809 only [2].
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How Sevana Care helps
Sevana Care has an inspection checklist you can work through between visits. Its Required postings section has an item for licensing reports. You mark an item checked, and the row shows how many days are left until the next check, or how many days it is overdue. Sevana Care does not track the LIC 809 or its plan of correction dates. See Inspections in the sample home.
More in Postings, records and inspections
Sources
- CDSS, LIC 809 (9/23), Facility Evaluation Report (PDF)
- CDSS, Forms and Publications (I-L)
- CDSS, Evaluator Manual, Reference Material for Documentation (PDF)
- CDSS, Evaluator Manual, Reference Material for Facility Evaluation/Visit (PDF)
- California Code of Regulations, Title 22, § 87756, Evaluation Visit (Westlaw)
- California Health and Safety Code § 1569.33 (leginfo)
- California Code of Regulations, Title 22, § 87759, Follow-up Visits to Determine Compliance (Westlaw)
- CDSS, LIC 9098 (4/09), Proof of Correction(s) (PDF)
- California Health and Safety Code § 1569.49 (leginfo)
- California Health and Safety Code § 1569.185 (leginfo)
- CDSS, LIC 9058 (3/22), Applicant/Licensee Rights (PDF)
- California Health and Safety Code § 1569.38 (leginfo)
- CDSS, LIC 9099 (12/16), Complaint Investigation Report (PDF)
- CDSS, LIC 9102TV (2/19), Advisory Notes – Technical Violation (PDF)
- CDSS, LIC 9242 (9/19), Entrance Checklist (PDF)
- CDSS, LIC 812 (8/06), Detail Supportive Information (PDF)
- CDSS, PIN 26-02-ASC, Approval of Section 100 Regulation Package Related to Civil Penalties for RCFEs (6/19/2026, PDF)