LTCO :: Complaint Form


		Long Term Care Ombudsman Services of Santa Barbara County

Welcome to the Long-Term Care Ombudsman Program

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	Our Mission Our mission is to advocate for dignity, quality of life, and quality of care for all residents in long term care facilities.

	LTC Facility Complaint Form


	1.	Please provide your information:
	Name:
	Address:
	City:		State:	Zip:
	Phone:
	Email:

	2.	Please provide location and contact information for the facility.
	Name:
	Address:
	City:		State:	Zip:
Phone:

	3.	Please describe in detail the nature of the complaint:



	4.	May we contact you for further information?
		Yes No


		Submit Complaint Form:

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