Complaint Form

Date (required)

Your Name (required)

Your Email (required)

Your Phone (required)

Facility Name (required)

City (required)

Resident Name (required)


Brief Complaint Statement

Please enter the text below

In accordance with Federal and State Laws, your name and all pertinent information are confidential.
You will be contacted by Solano Long-Term Care Ombudsman Intake for additional information.