This form should be used as a guide for what to include
when filing a nursing home abuse complaint.
Name of person filing complaint
Daytime phone number_____________
Evening phone number_____________
Name of facility_____________________________________________
Address of facility____________________________________________
Name of resident on whose behalf the complaint is made:
Date(s) of incident:
Shift(s) when incident(s) occurred: Day/Afternoon/Night
Witnesses to Event:
Records to be examined:
Name of staff person(s) involved:
Mark off the following statements if they are applicable
to your situation.
__ I have sent a copy of my complaint to the appropriate
Licensing and Certification district office of the California
Department of Health Services.
__ I am sending an additional copy to CANHR/APE/AoA
(or other applicable resident advocate organization).
__ I wish to know the name of the investigator assigned
to this complaint.
__ I wish to speak with the investigator before they
make their onsite visit to investigate the claim.
__ I wish to accompany the investigator to the facility
when the complaint investigation is being done.
__ I wish to remain anonymous. I do not want my name
or identity known to the nursing facility.
__ I would like a copy of the final complaint report,
and notice of my rights if I am not satisfied with your
If the safety and health of your loved one is in jeopardy, and you feel that they have suffered some form of nursing home abuse or neglect, contact us to speak with an attorney.