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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

Last Name:

First Name:

Middle Initial:

Address:

City:

State:

Zip Code:

Phone Number(home):

Phone Number(work):

Section 2 - Confidentiality

Do you wish to remain anonymous? Yes

Section 3 - Residents/Patients/Clients

Last Name:

First Name:

Middle Initial:

Relationship to the complainant

Resident still in the facility?Yes

Section 4 - Complaint Against

*Facility/Provider Name:

Address:

City:State:

Zip Code:

Section 5 - Complaint

*Date of Alleged Event (MM/DD/YYYY)

*Time of Alleged Event (HH:MM AM or PM)

*What Happened?

*How did it happen?

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