Welcome to the State of California

Complaint Against a Health Facility/Provider

To submit a complaint to the Licensing and Certification Program against a health facility/provider, please fill out the fields below and click the submit button. Please provide as much detailed information about the complaint to help us complete a thorough investigation.

Printable Complaint Form (PDF)Opens a new window

*Fields denoted with an asterisk are required fields

Section 1 - Your contact information

Section 2 - Confidentiality

Yes

Section 3 - Residents/Patients/Clients

Yes

Section 4 - Complaint Against

Section 5 - Complaint

 (MM/DD/YYYY)

 (HH:MM AM or PM)

Step 6 - Verification

To successfully submit your complaint, please enter the 5 character security code located in the light blue box.

If you are unable to read the security image on this page dial 7-1-1 and ask the Relay California agent to assist you.Enter the security code above