California Adult Protective Services (APS) Report of Suspected Elder / Dependent Adult Abuse

CALIFORNIA REPORT OF SUSPECTED ELDER OR DEPENDENT ADULT ABUSE

SECTION 0 — URGENT ACTION CHECKLIST

☐ If the elder/dependent adult is in immediate physical danger, call 911 first.
☐ Telephonic report made to APS hotline: 1-833-401-0832 (statewide; auto-routes by zip code) — Date / Time: [__/__/____] [__:__]
☐ Confidential internet report submitted (where county supports): URL [_______________] — Confirmation #: [_______________]
☐ For abuse occurring in a long-term care facility (SNF / RCFE / ICF), report to CDPH Licensing & Certification AND Long-Term Care Ombudsman (1-800-231-4024) instead of / in addition to county APS — see § 15630(b)(1).
☐ Written report (SOC 341) transmitted within two (2) working days of telephonic report.
☐ Cross-report to law enforcement (if physical abuse, sexual abuse, abandonment, abduction, or financial abuse suspected) — § 15630(b)(2).
☐ Cross-report to local district attorney (where required) — § 15633.

SECTION 1 — REPORTER INFORMATION

SECTION 2 — ELDER / DEPENDENT ADULT (VICTIM)

Statutory Classification

☐ "Elder" — any person age 65+ residing in California (W&I § 15610.27).
☐ "Dependent adult" — any person 18-64 with physical / mental limitations restricting ability to carry out normal activities or protect own rights, including individuals admitted as inpatients to 24-hour facilities (W&I § 15610.23).

SECTION 3 — SUSPECTED ABUSE

A. Type of Abuse (check ALL that apply)

☐ Physical abuse — § 15610.63 (assault, battery, unreasonable physical constraint, prolonged/continual deprivation of food/water, sexual assault/battery, use of a physical or chemical restraint, use of medication for purposes inconsistent with care plan)
☐ Neglect (by another) — § 15610.57(a)(1) (failure of caregiver to exercise the degree of care a reasonable person would exercise)
☐ Self-neglect — § 15610.57(b)(5)
☐ Financial abuse — § 15610.30 (taking, secreting, appropriating, obtaining, or retaining real or personal property for wrongful use, with intent to defraud, or by undue influence)
☐ Abandonment — § 15610.05
☐ Abduction — § 15610.06
☐ Isolation — § 15610.43
☐ Mental suffering / psychological abuse — § 15610.53
☐ Sexual abuse (by reference; reportable under § 15630)
☐ Other [_______________________]

B. Incident Description

Date(s) of incident: [__/__/____] to [__/__/____]
Location of incident: [________________________________]
Frequency: ☐ Single incident ☐ Recurring ☐ Ongoing/chronic ☐ Pattern over [____] months/years

Narrative (specific facts, dates, statements, observations — avoid conclusions; quote victim verbatim where possible):

[________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________]

C. Observable Indicators

D. Photographs / Evidence

☐ Photographs taken (permitted under W&I § 15630(g) and immune under § 15634(b))
☐ Documents collected (medical records, bank statements, deeds, etc.) — describe: [________________________________]
☐ Audio / video recordings (note legality under Penal Code § 632) — describe: [________________________________]

SECTION 4 — ALLEGED ABUSER / PERSON OF INTEREST

SECTION 5 — WITNESSES

SECTION 6 — CROSS-REPORTING

Per W&I § 15630(b) and § 15633, certain reports must be cross-reported. Mark all that were made:

☐ County APS — [_______________ County]; report # [_______________]
☐ Local law enforcement — [_______________ Agency]; case # [_______________]
☐ District Attorney — [_______________ County]
☐ CDPH Licensing & Certification (SNF/ICF) — district office [_______________]
☐ DSS Community Care Licensing (RCFE / ARF) — regional office [_______________]
☐ Long-Term Care Ombudsman — 1-800-231-4024
☐ Bureau of Medi-Cal Fraud and Elder Abuse (DOJ) — for facility / fraud schemes
☐ Department of Insurance (annuity / insurance fraud)
☐ Adult Protective Services in another county (victim relocated)
☐ Tribal authority (if applicable)
☐ Federal agency — [_______________]

SECTION 7 — IMMUNITY AND CONFIDENTIALITY ACKNOWLEDGMENT

Under W&I § 15634:

No care custodian, clergy member, health practitioner, mandated reporter of suspected financial abuse of an elder or dependent adult, or employee of an adult protective services agency or a local law enforcement agency who reports a known or suspected instance of abuse of an elder or dependent adult shall be civilly or criminally liable for any report required or authorized by this article.

Permissive (non-mandated) reporters are immune unless it can be proven the report was knowingly false (§ 15634(a)). Photography of a suspected victim taken pursuant to a report carries the same immunity (§ 15634(b)).

Under W&I § 15633.5, the identity of the reporter is confidential and may not be disclosed except: (i) to specified agencies for investigation; (ii) under court order on a showing of good cause; (iii) where the reporter consents in writing; or (iv) as otherwise required by law.

I acknowledge I have read and understood my rights and protections as a reporter:

Reporter signature: [________________________________] Date: [__/__/____]

SECTION 8 — CRIMINAL EXPOSURE FOR FAILURE TO REPORT

Failure of a mandated reporter to report physical abuse, abandonment, abduction, isolation, financial abuse, or neglect is a misdemeanor punishable by up to 6 months in county jail and/or a $1,000 fine (W&I § 15630(h)). Where the failure to report results in death or great bodily injury, the offense is punishable by up to one year in county jail and/or up to $5,000 fine. Mandated reporters of financial abuse who willfully fail to report under § 15630.1 are subject to civil penalties up to $1,000 (or $5,000 for intentional failure).

SECTION 9 — POST-REPORT FOLLOW-UP (Reporter / File Copy)

SECTION 10 — REPORTER CERTIFICATION

I certify, under penalty of perjury under the laws of the State of California, that the foregoing report is made in good faith and based on facts known to me or facts I have reasonable cause to suspect. I understand this report and the SOC 341 will be transmitted to the appropriate investigative agency under the Elder Abuse and Dependent Adult Civil Protection Act.

SOURCES AND REFERENCES

• California Department of Social Services — Adult Protective Services: https://www.cdss.ca.gov/adult-protective-services
• CDSS Form SOC 341 (Report of Suspected Dependent Adult/Elder Abuse): https://cdss.ca.gov/portals/9/fmuforms/q-t/soc341.pdf
• Statewide APS Hotline: 1-833-401-0832 (24/7)
• W&I § 15630 (FindLaw): https://codes.findlaw.com/ca/welfare-and-institutions-code/wic-sect-15630/
• W&I § 15630.1 (financial abuse mandated reporters): https://california.public.law/codes/welfare_and_institutions_code_section_15630.1
• W&I § 15634 (immunity): https://codes.findlaw.com/ca/welfare-and-institutions-code/wic-sect-15634.html
• California Legislative Information (W&I Code): https://leginfo.legislature.ca.gov/faces/codes_displayexpandedbranch.xhtml?tocCode=WIC
• CANHR — Recognizing and Reporting Elder Abuse: https://canhr.org/recognizing-and-reporting-elder-abuse/
• California Long-Term Care Ombudsman: 1-800-231-4024 / https://aging.ca.gov/Programs_and_Services/Long-Term_Care_Ombudsman/
• CDPH Centralized Complaint Intake: 1-800-236-9747 / https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/ContactUs.aspx
• Bureau of Medi-Cal Fraud & Elder Abuse (CA DOJ): https://oag.ca.gov/bmfea

This template is a working tool for reporters and counsel; it does not satisfy the statutory written-report requirement on its own. The official Form SOC 341 (CDSS) must be transmitted within two working days of the telephonic report. Reporters should retain a confidential copy of all transmissions and acknowledgments.