Ccld lic forms. name of client or child .

Ccld lic forms One copy will be retained by the Operator and the other you may retain for your records. lic 9020a (6/17) (confidential) page_____ of _____ residentnameand ambulatory status physician representative language read room identifier ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden lic 702 (1/08) (confidential) word used for urination* is child toilet trained? * yes no is child presently under a doctor’s care? yes no if yes, name of doctor: does child take prescribed medication(s)? yes no if yes, what kind and any side effects: if yes, at what stage: are bowel movements regular? * yes no any eating problems? The Community Care Licensing (CCL) Program along with several programs from the former Department of Benefit Payments were combined to form the current Department of Social Services. applicant seeking a license for a new Adult Day Program (ADP), Adult Residential Facility (ARF), Adult Residential Facility for Persons with Special Health Care Needs (ARFPSHN), Community Retain this form for your records. 00 check or LIC 627 (9/08) (CONFIDENTIAL) WORK PHONE. If you Please complete the entire form. 3. ” LIC 9221 (8/08) TIME GIVEN. The DOJ only accepts electronically transmitted fingerprint images and related information to process requests for criminal record checks. What Are The Fees CCLD Charges? LIC 613A (8/08) Title: LIC 613A Personal Rights Child Care Centers Author: CDSS Subject: Personal Rights Child Care Centers Created Date: 20000314144320Z If you have problems accessing them, please send your comments to ord@dss. 9. ELIMINATE POTENTIAL HAZARDS IN CLASSROOMS AND THROUGHOUT THE SITE: Bolt bookcases in high-traffic areas securely to wall studs. Request for Live Scan Service (form LIC 9163 (12/15), signed by the Live Scan operator. The LIC 9052 (3/03) Title: LIC 9052 Author: CDSS Created Date LIC 613C-2 (1/19) Page 1 of 7 EXPLANATION: This form describes the personal rights of residents in privately operated Residential Care Facilities for the Elderly (RCFEs). lic 9020a (6/17) (confidential) page_____ of _____ residentnameand ambulatory status physician representative language read room identifier ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden Children’s Crisis Residential Program (CCRP): A facility licensed by CCLD as a STRTP and approved by the State Department of Health Care Services (DHCS), or a county mental health plan to which DHCS has delegated approval authority, to operate a children’s crisis residential mental health program approval to serve children, nonminor Licensees or license applicants may contact their local Community Care Licensing Division (CCLD) office to verify the individual's status. www. pdf Author: CDSS Created Date: 1/22/2008 8:52:06 AM License, Certification, Applicant Volunteer Home Care Aide Registry Applicant 1. Originating Response Indicator (ORI): Preprinted 2. date of last tb test. Yes No Pending This form is intended for keeping a current roster of all the facility personnel, other adults and licensees residing in the facility, including backup persons, volunteers and licensee if administrator/director. PIN 22-13-CCLD - Announcing the Community Care Licensing Complaint Web Page; PIN 22-12-CCLD - Information On The Use Of The Child Abuse Central Index For State Licensed Facilities (LIC 198A Form) PIN 22-11-CCLD - Guardian Webinar for Licensees and Providers; PIN 22-10-CCLD - Estimated SSI/SSP Payment Standards Effective January 1, 2023 Go to this Reference Statement form and print out three copies: LIC 301E form. Coronavirus General Question Inbox: CCLCOVID-19INFO@dss. Browse the alphabetical list of forms and publications from I to L, including LIC 01A, LIC 01C, LIC 03, and Welcome to the Community Care Licensing Division. This is detailed in SB 1104 chapter 229 amending Health & Safety Code 1523. PIN 22-13-CCLD - Announcing the Community Care Licensing Complaint Web Page; PIN 22-12-CCLD - Information On The Use Of The Child Abuse Central Index For State Licensed Facilities (LIC 198A Form) PIN 22-11-CCLD - Guardian Webinar for Licensees and Providers; PIN 22-10-CCLD - Estimated SSI/SSP Payment Standards Effective January 1, 2023 GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING Instructions for the LIC 9163 1 Originating Response Indicator (ORI): Enter the CCLD or TrustLine ORI code below that pertains to you. Child Care Licensing Program 744 P Street, MS T9-15-48 Sacramento, CA 95814 Telephone: (916) 651-6040 Email to cclwebmaster@dss. Find forms and publications related to licensing and child care programs in California. LIC 9163 (3/23) Page 2 of 6. FEMALE . Applicants/licensees who are corporations shall attach board resolutions authorizing this delegation. Title: CONSENT FOR EMERGENCY MEDICAL TREATMENT-Child Care Centers Or Family Child Care Homes form Author: CDSS Created Date: Contact Us. Contact Us. I/We am/are authorized to sign this application on behalf Administrator Forms: LIC 9214 – Application for Administrator Certification – Both initial and renewal applicants submit this form. (Sec. , all individuals, each partner in a partnership, or chief executive officer or authorized representative in a corporation. ” 03502 ( ) Multiple Programs (forms common to more than one program) Notice of Action: ( NA ). Show coverage for physician may assist the applicant in completing this form. Keep a copy of this form and use the area below to note the date and time we will visit your home and the name and telephone number PIN 23-08-CCLD notifies all Community Care Licensing Division (CCLD) Licensees and . These forms contain information that is unique to each agency and this information must be on the form before arriving to have fingerprints taken. To request a clearance transfer between state licensed facilities, a licensee or license applicant must submit an LIC 9182, Criminal Record Clearance Transfer Request form, to the local CCLD office CCLD Complaint Hotline. RECEIVED BY LICENSING PR. lic 501 (3/99) (over) date. Return the original form to the director of the licensed center. enter principal business mailing address(es) on Applicant Information (LIC 215). To request a LIC 622 (3/99) (CONFIDENTIAL) II. CITY . facility file number. It includes instructions, guidelines, This is a PDF form for applying for a license to provide child care in your own home in California. all facilities [except child care center/family child care home completes lic 700] 1. gov Child Care Advocates- (916) 654-1541. A separate Group Home Program Statement must be completed • LIC - indicates Licensing forms • MPP - Manual of Policies & Procedures (contains AFDC-FC rate setting regulations) Contact Us. DATE. Owner/Landlord Consent Form (LIC 9149). This form describes the personal rights to be afforded each person admitted to an adult community care facility. 881 and 1596. signature on this form may serve as a receipt for cash distribution to the client/resident. e. The licensee not exceed the conditions, limitations, and capacity specified the license (if fire cleararxe capacity is exceeded, use Zero Tolerance item located above) The that a complete, current for each child is This form may be used to show compliance with Health and Safety Code Section 1596. I hereby authorize release of medical information contained in this COMMUNITY CARE LICENSING DIVISION LIC 9214 (9/21) PAGE2 OF 2 Instructions: FOR ALL APPLICANTS: Use the applicable following checklist to ensure your application is complete (including all supporting forms and fees) and submit it to: CDSS, Administrator Certification Section (ACS), 744 “P” Street, MS 9-17- 47, Sacramento, CA 95814. Personal Rights – Child Care Centers – LIC 613A physician may assist the applicant in completing this form. Other. What is a background check? As part of the background check process you must be fingerprinted and tell whether you have ever been Contact Us. Upload proof of completion of CETP hours in the form of a certificate of completion under “Education Credits. Working Title: Check the appropriate box. 7 %âãÏÓ 677 0 obj > endobj 754 0 obj >/Encrypt 678 0 R/Filter/FlateDecode/ID[95A5FF2F5E32BF409EF0C75A4C9BFEB9>]/Index[677 176]/Info 676 0 R/Length 176/Prev out of state in the last five (5) years you must complete this form and sign below to authorize a check of the child abuse/neglect registry in that state in If you have any questions about this form, please contact your local licensing regional office. The California Department of Social Services, Community Care Licensing Division, is not responsible for the accuracy or content of any information contained within linked websites. 153(k). If you use a Live Scan Operator other than IBT - L1, you will need to take 2 copies of this form. This checklist is provided for your convenience so that you may determine what areas will require correction. Miscellaneous Forms: ( GEN ) Publications physician may assist the applicant in completing this form. gov Community Care Licensing Division Child Care Licensing Program 744 P Street Sacramento, CA 95814 Phone: (916) 651-6040 This form is intended to meet the requirements of Health and Safety Code Sections 1596. Personal Rights – Child Care Centers – LIC 613A The LPA should fill out this form using the following instructions. This offsets the General Fund expenditure and allows the division to maintain its critical functions. Type of Agency or Facility: Check the appropriate box for type of facility as defined in California Code of Regulations, Title 22, Interim Licensing Standards, and/or Health and Safety Code. We also check the criminal background of all adults who want to work, reside in or have contact with clients being cared for in a community care facility. LIC 308 (11/02) (PUBLIC) Title: LIC 308. Mail this completed two-page application, the complete Criminal Record Statement (LIC 508), and a $35. I/We understand the requirements to report known or suspected child abuse (LIC 9108). 10. 1. ” 03502 ( ) Please provide a report on above-named child using the form below. IDENTIFYING INFORMATION . PIN 23-09-CRP - ACIN I-28-23 Updated Guidance on Face Covering Requirements Related to Coronavirus Disease 2019 (Covid-19) In Children’s Residential Settings (Supersedes ACIN I-34-22/PIN 22-05-CRP); PIN 23-05 Emergency Disaster Drill Log California Community Care Licensing (CCL) Requirements Licensed child care programs must conduct emergency drills at least once every 6 months. A signed copy of these Contact Us. This form is intended to meet this requirement. social security number (optional) date of birth age sex 2. D. This list is designed to cover the areas reviewed by your analyst at the Contact Us. 889) and the regulations in Title exhaustive treatment of the licensing regulations specific to RCFEs and cannot be used as a substitute for having the requisite working knowledge of STATE OF CALIFORNIA − HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 2OF 8 RESIDENT AND RESPONSIBLE PERSON OR CONSERVATOR (IF ANY): Upon satisfactory and full disclosure of the personal rights described on this form, complete LIC 402 Surety Bond Author: CA Dept of Social Services Created Date: 20020108221017Z This form may be used to show compliance with Health and Safety Code Section 1596. Title: LIC508D. FACILITY ADDRESS. If you see something, let us know! To file a complaint regarding a state licensed community care facility , child care facility, Forms/Brochures; Fiscal/Financial; Data Portal; Home. ca. Working Title: Check the appropriate box 3. address telephone () 3. 1. LIC 503 (3/99) (PERSONAL) Please provide a report on above-named child using the form below. address telephone ( ) 4. 80026(h)(1)(A) and 87227(g)(1)(A). facility address. FOR GENERAL PARTNERS - In addition to the LIC 401a, Part II, for the partnership a separate Form LIC 401a must be completed for each general partner. Sacramento, CA 94244-2430. (Note: You do not need to wait for your Live Scan results before submitting your application. LIC 625 (8/99) CONFIDENTIAL. A. These documents are in Word format only. of Social Services Created Date: 20001106093126Z physician or dentist to be called in an emergency names of persons authorized to take child from the facility (child will not be allowed to leave with any other person without written authorization from parent or authorized representative) LIC 9217 (3/05) Page 2 of 2 THERE ARE MANY OTHER THINGS YOU CAN DO TO MAKE YOUR HOME SAFE THAT MAY NOT BE IN REGULATIONS. i/we shall no tify the licensing agency immediately if a COMMUNITY CARE LICENSING . pdf Title: LIC 503 Health Screening Report - Facility Personnel Author: CA Dept of Social Services Created Date: 19991007111135Z GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING Instructions for the LIC 9163. Originating Response Indicator (ORI): If you have any questions about this form, please contact your local licensing regional office. OR COUNTY OF _____ WELFARE OR SOCIAL SERVICES DEPARTMENT CHILD CARE LICENSING The California Department of Social Services Community Care Licensing Division’s website at www. If you see something, let us know! To file a complaint regarding a state licensed community care facility , child care facility, TransfertotalBalanceDueonline54toLIC403,line19. notification o f parents ’ rights of $35. Temporary Forms: Search ( Temp ) for additional program forms. Community care was originally envisioned as a normalizing and least restrictive environment for persons needing basic care and supervision that would assist them PIN 23-08-CCLD notifies all Community Care Licensing Division (CCLD) Licensees and . the Foster Family Agency or Children’s Residential Agency will need to resubmit the applicable forms to Title: CONSENT FOR EMERGENCY MEDICAL TREATMENT-Child Care Centers Or Family Child Care Homes form Author: CDSS Created Date: 1/22/2008 8:59:03 AM lic 9020 (8/11) (confidential) page_____ of _____ physician responsible person ambulatory status restricted condition(s) (if applicable) client/resident name room identifier (if applicable) ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden The LPA should fill out this form using the following instructions. ORI: A0448 CA Dept of Social Services PO BOX 94244. SOCIAL SECURITY NUMBER: NEXT OF KIN: PERSON RESPONSIBLE FOR THIS PERSON’S FINANCES: PATIENT’S CCLD Complaint Hotline. Applicant(s) Name(s): authentication of this form, and my intent to be bound by it. pdf. MALE . Prevention Enhancing technical support to licensees from LPAs and the Technical Support Program; developing resource guides and trainings for licensees and potential licensees; and deploying online resources Contact Us. HEALTH (Describe overall health condition including any dietary limitations) PHYSICAL DISABILITIES (Describe any physical limitations including vision, hearing or Statement for county placement, Community Care Licensing Division (CCLD), and Aid to Families with Dependent Children-Foster Care (AFDC-FC) rate setting. name of client or child . Originating Response Indicator (ORI): Preprinted. A signed copy of these for a license to operate a community care facility. Out-Of-State Child Abuse/Neglect Report Request – LIC 198B. Then, the individual should ask three people who know him/her but who are not relatives or family members to fill out a form. Out-Of-State Disclosure And Criminal Record Statement – LIC 508D. Title: For Residential Care Facilities for the Elderly, this form is not required at the time of admission but must be completed if it is determined that an elderly resident’s needs have not been met. The form includes instructions, guidelines, and information for applicants, employers, and CARE FACILITY FOR THE ELDERLY LICENSE LIC 200 (2/24) PUBLIC Page 1 of 5 (See Instructions on Pages 4 and 5) 1. OGRAM ANAL. 798 before a child care licensee or staff person administers inhaled medication to a child in care. Notice of Action Documents: ( M ). An . Retain one copy in the teacher’s file at the licensed center and return a copy to the teacher. date admitted to facility These Applicants must provide the CPMB with the applicable 508 (LIC 508D or 508 OOS), LIC 198B and any state-specific required documentation to complete the OSCA check. Application Forms For A Family Child Care Home License These forms are required to be completed by an applicant for a Family Child PROPERTY OWNER/LANDLORD CONSENT FORM (LIC 9149) - You must obtain consent from your landlord when: 1. The Applicant is not eligible until the OSCA check is cleared. IF YOU HAVE ANY QUESTIONS, CALL YOUR LICENSING PROGRAM ANALYST. Enter area code with telephone number. PERSON(S) RESPONSIBLE METHOD OF NEEDS OBJECTIVE/PLAN TIME FRAME FOR IMPLEMENTATION EVALUATING PROGRESS LIC 613C-2 (1/19) Page 1 of 7 EXPLANATION: This form describes the personal rights of residents in privately operated Residential Care Facilities for the Elderly (RCFEs). Community Care Licensing Division Statewide Children's Residential Program Office 744 P Street, MS 9-14-880 Sacramento, CA 95814 (916) 651-5380 LIC 625 - The Golden Years Guest Home 9. PIN 22-14-CCLD - Assembly Bill (AB) 1720 Implementation; PIN 22-13-CCLD - Announcing the Community Care Licensing Complaint Web Page; PIN 22-12-CCLD - Information On The Use Of The Child Abuse Central Index For State Licensed Facilities (LIC 198A Form) PIN 22-11-CCLD - Guardian Webinar for Licensees and Providers If a new or additional license or facility number needs to be added to an existing Guardian user account please complete a Licensee User Account Access form and submit to GuardianLoginSupport@dss. 00, payable to the California Department of Social Services, and complete the LiveScan form (LIC 9163) to submit fingerprints. APPLICANT’S NAME HEALTH (Describe overall health condition including any dietary limitations) PHYSICAL DISABILITIES (Describe any physical limitations including vision, hearing or speech) File the medical exemption form specifying the exempted immunization(s) in the pupil’s record. childcareadvocatesprogram@dss. It requires personal information, Download and fill out this form to request live scan service for community care licensing purposes. FOR INDIVIDUALS AS SOLE PROPRIETORS - Part I of the LIC 401a must also be completed. of Social Services Created Date: The applicant or licensee is required to sign this form attesting to the financial information. AGE . In addition, this form is submitted by a previously certified administrator who did not renew their certificate within four (4) years from the date of expiration and so must reapply. FACILITY NAME. gov Your application for an Adult Residential Facility license has been accepted. Authorized Applicant Type: Indicate the facility type where you For CCLD operations pending license or other pending business operations the reported amounts may be estimated. lic 9020a (6/17) (confidential) page_____ of _____ residentnameand ambulatory status physician representative language read room identifier ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden Forms/Brochures; Fiscal/Financial; Data Portal; Home. if yes, please list all names used. Type or print clearly using black ink. STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION Department of Social Services, Community Care Licensing Division (CCLD) must comply with law in the RCFE Act (Health and Safety Code sections 1569 through 1569. 882 which require that employees be informed of their rights, at the time of employment, to filing complaints against their employer for violating any licensing law or regulation. social security number: (voluntary for id only) - - date of last physical examination. gov 2. if yes, facility name and number: licensing agency name: lic 200a (6/08) page 1 of 2 16. g. Page 2 of 2 . LIC 301E form. PAGE 2 OF 2 . community care licensing . MEDICATION DESTRUCTION RECORD INSTRUCTIONS: Prescription drugs not taken with the client/resident upon termination of services or otherwise disposed of shall be destroyed in the facility by the Administrator or www. SEX . It asks about any criminal convictions in California or other This is a PDF form for applicants who need to submit fingerprints for criminal history information for various types of community care licensing in California. Your honest reply will help us ensure high quality care in our licensed The license applicant or licensee who is seeking the exemption transfer must provide a LIC 508, and verify the individual’s identity and include a copy of the person’s driver’s license, permanent resident card or a valid photo identification issued by CCLD Complaint Hotline. Transfer Request Form (LIC 9182) and the Criminal Record Exemption Transfer Request Form (LIC 9188) following the implementation of Senate Bill 1093 and Assembly Bill 1720. CCLD Complaint Hotline File a Complaint 1-844-LET-US-NO For Residential Care Facilities for the Elderly, this form is not required at the time of admission but must be completed if it is determined that an elderly resident’s needs have not been met. All prescription and nonprescription medications shall be maintained with the child’s name and The license applicant or licensee who is seeking the transfer must provide a LIC 508, and verify the individual’s identity and This form may only be used to request a clearance transfer between state licensed facilities/organizations. The Department of Motor Vehicles offers a license plate that can help our kids. This person has selected you to write a reference statement on his/her behalf. responsible person or placement agency . Problems with downloading forms? CDSS forms and publications are available only in Portable Document Format (PDF). ) If applicable, for RCFE applicants only, a copy of your current Note: Residential Care Facilities for the Elderly may use this form to assess the person’s functional capabilities as required in Section 87584 of the regulations. release of information . name of facility. Signed: Title: County Where Signed: Date: Signed: Title: County Where Signed: Date: 23. (SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE) (TODAY’S DATE) PART B – PHYSICIAN’S REPORT (TO BE COMPLETED BY PHYSICIAN) LIC 610D (12/21) Page 1 of 9 EXPLANATION: This form is provided as a courtesy to all adult facility applicants and licensees. Orientation Meeting Family Child Care Home – LIC 186A. 4. LIC 9149 (8/14) - Family Child Care Home Property Owner/Landlord Consent Form; LIC 9150 (8/14) - Parent Notification - Additional Children In Care ; LIC 9151 (8/14 LIC 627C (ENG/SP) (4/00) (CONFIDENTIAL) Title: LIC 627C Author: CA Dept. NAME OF CLIENT/RESIDENT: FACILITY NUMBER: YEAR Forms/Brochures Fiscal/Financial Data Portal CDSS Programs Community Care Licensing Orientations. 5) The facility representative’s signature is necessary to be able to verify a cash transaction. source of water for human consumption i/we shall ensure that all persons su bject to fingerprint requirements shall also submit a child abuse index check form to the department of justice. , Social Worker and other consultant(s)]. ) LIC 9163 (3/11) PAGE 3 OF 4 Licensees shall use this form to delegate the above authority to appropriate staff. lic 700 (10/19) (confidential) page 2 of 2 names of persons authorized to take child from the facility (child will not be allowed to leave with any other person without written authorization from parent or authorized representative) name relationship time child will be picked up signature of parent/guardian or authorized representative date Emergency Disaster Plan (LIC 610, LIC 610A and 610A (SP)) and be made accessible to the public. APPLICANT’S NAME HEALTH (Describe overall health condition including any dietary limitations) PHYSICAL DISABILITIES (Describe any physical limitations including vision, hearing or speech) A major component of the Community Care Licensing Division (CCLD) program budget is now funded through the collection of licensing fees. patient’s birthdate LIC 9158 (11/04) Title: LIC 9158 Author: CA Dept of Social Services Created Date: 20021104192110Z abuse or neglect, or reasonably suspects that abuse or neglect occurred, shall complete form SOC 341, “Report of Suspected Dependent Adult/Elder Abuse” for each report of known or suspected instance of abuse (physical abuse, sexual This form must be updated and submitted to the Licensing Agency each time there is a change in partners, officers or changes in the corporation or limited liability company as provided in the Callifornia Code of Regulations Title 22, Section 80034(a)(2), or 87235(a)(5), or 101185(a)(2). PARENT’S INSTRUCTIONS: 1. Retain one copy in the teacher’s personnel file at the licensed center. APPLICANT’S NAME . COVID-19 2020 PINs; 2021. %PDF-1. have you ever been employed under a different name? yes no. The form includes instructions, questions, This form is required for persons associated with licensed facilities or Home Care Aide Registry applicants in California. Then, the individual should ask three people who know him/her but who are not relatives or family members STATE OF CALIFORNIA − HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 2OF 8 RESIDENT AND RESPONSIBLE PERSON OR CONSERVATOR (IF ANY): Upon satisfactory and full disclosure of the personal rights described on this form, complete LIC: Licensing Forms (CCLD) MPP: Manual of Policies & Procedures STRTP: Short -term residential therapeutic program WIC: Welfare & Institutions Code . You plan to expand your Small Family Child Care Home capacity CCLD Complaint Hotline. Authorized Applicant Type - Enter from list on Page 2, “DOJ Abbreviated CCLD Facility/Organization Type. name of nearest relative (optional) relationship . Enter the initials of the staff reviewing the pupil’s record. I. Authorized Applicant Type: Indicate the facility type where you will LIC 624A Death Report Licensee Must Report the Death of a Client of Any Cause, Regardless Of Where The Death Occurred Author: CDSS Subject: Death Report Licensee Must Report the Death of a Client of Any Cause, Regardless Of Where The Death Occurred Created Date: 20010125160031Z LIC 9108 (3/05) PAGE 1 OF 2 POSITION FACILITY NUMBER STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIALSERVICES . ccld. 695 and California Code of Regulations, Title 22, Section 87212, Emergency Disaster Plan. gov LIC 279A (5/17) PAGE 1OF7 ForA FamilyChild Care Home License These forms are required to be completed by an applicant for a Family Child Care Home license: CLICKBELOW TO ACCESSEACH FORM. _____ _____ (SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE) (TODAY’S DATE) This form must be completed by all applicants for a facility license, (i. Move heavy books and items from high to low shelves. Orientations For Community Care Facilities. CLIENT’S NAME . If you see something, let us know! To file a complaint regarding a state licensed community care facility , child care facility, or home care organization, visit our Complaint Hotline Page for contact LIC 301E (7/03) The above named person has applied to operate, work or reside in a community care facility serving the client group indicated above. HEALTH (Describe overall health condition including any dietary limitations) PHYSICAL DISABILITIES (Describe any physical limitations including vision, hearing or speech) removal date, and ensure form is signed by all required persons specified above. . PERSON(S) RESPONSIBLE METHOD OF NEEDS OBJECTIVE/PLAN TIME FRAME FOR IMPLEMENTATION EVALUATING PROGRESS The original of this form, along with copies of transcripts or other relevant documentation, must be kept in the facility file at the District Office. It includes instructions, certifications, and attachments for different types of applications and This is a PDF form for applying for a license to operate a community care facility or residential care facility for the elderly in California. Pursuant to the recently passed Assembly Bill (AB) 120, prospective and current Certified Administrators have the option to satisfy live training requirements for Initial Certification Training Programs (ICTP) and Continuing Education Training Programs (CETP) via Department-approved in-person or live Once completed, the results of the DOJ fingerprint check are sent electronically to the Care Provider Management Branch (CPMB) of the Community Care Licensing Division (CCLD). CCLD Complaint Hotline. Title: LIC9163. In accordance with PIN-20-20-CCLD, a Licensee User Access Form has been sent to all licensee mailing addresses, requesting information to LIC 610E (3/19) Page 1 of 9 Section Page Assignments During an Emergency or Disaster 2 Resident Information 3 Utility Shut-Off 3 Facility Exit Doors 3 the elements on this form pursuant to Health and Safety Code section 1569. Receive, from the licensee, the Caregiver Background Check Process form. Be informed, by the licensee, that the facility has or does not have liability insurance (or a bond) that covers injury to clients due to the negligence of the licensee or employees of the facility. Submitting a separate LIC 9214 is not required. DATE: ENDING DATE TIME OF DAY. FACILITY NUMBER lic 700 (10/19) (confidential) page 2 of 2 names of persons authorized to take child from the facility (child will not be allowed to leave with any other person without written authorization from parent or authorized representative) name relationship time child will be picked up signature of parent/guardian or authorized representative date Have a Heart, Be a Star, Help Our Kids. Penalty Review – LIC 178. gov or contact the CCLD Webmaster at cclwebmaster@dss. Telecommunication Device Notification Form (LIC 9158) is on file for clients with hearing/visual impairment. Community Care Licensing Division Administrator Certification Bureau (ACB) 744 P Street, MS 9-15-807 Sacramento, CA 95814 916-653-9300 Admincertinfo@DSS. STAFF SIGNATURE. ) This form is not a substitute for the Physician’s Report (LIC 602). b. It also provides the nondiscrimination notice to, and complaint information for, a resident and if applicable, their representative. Notification Of Initial Application Denial – LIC 192. Name of Client/Resident Social Security No. COVID-19 2021 PINs ; 2022. GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING Instructions for the LIC 9163 LIC 9163 (3/21) Page 2 of 6 1. (ALIEN REGISTRATION, OUT OF STATE DRIVER’S LICENSE OR I. TIME GIVEN. If you see something, let us know! To file a complaint regarding a state licensed community care facility , child care facility, or home care organization, visit our Complaint Hotline Page for contact information and more. California law REQUIRES If the person discloses that they have lived in another state within the last five (5) years, send this form and LIC 198B(s) to the Caregiver Background Check Bureau, 744 P Street, MS 9-15-62, Sacramento, CA 95814. Show license/certificate number if applicable for specialized staff [e. At the Live Scan site, the Live Scan operator will inform the individual of the charges , which include the transmission of the prints and all necessary services from the DOJ, the Federal Branch of CRP COVID-19 PINs Organized by Topic . The reverse side of this form may be completed and retained in Residential Care Facilities for the Elderly to meet the notice requirements of Health and Safety Code Section 1569. a. Type or print clearly. YST DATE DATE . ) If more space is required, attach additional sheet. The fees collected from the Kids Specialty License Plates are deposited in the Child Health and Safety Fund and used for programs that keep California kids safe, which include child care safety, child abuse prevention, and efforts to prevent childhood injuries. If you are interested in obtaining a California license to operate a community care facility, you must first attend an orientation. Ideclareunderpenaltyofperjurythattheforegoingandanyattachmentsaretrueandcorrect. Registered Home Care Aides of updates to the Criminal Background Clearance . GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING Instructions for the LIC 9163. You plan to expand your Small Family Child Care Home capacity LIC 508B (3/11) REQUIRED FORM - NO CHANGE PERMITTED . do you possess a valid california driver's license? yes no LICENSEE’S NAME: TELEPHONE: FACILITY LICENSE NUMBER: RESIDENT/CLIENT INFORMATION (To be completed by the resident/authorized representative/licensee) NAME: TELEPHONE: ADDRESS: NUMBER . 1562. Complete the required fields. STATEMENT ACKNOWLEDGING REQUIREMENT TO REPORT CHILD ABUSE NOTE: RETAIN IN EMPLOYEE/LICENSEE FILE . 2. Complete the appropriate row in the Status of Requirements section. LIC 9163 (3/11) PAGE 4 OF 4. PERJURY STATEMENT - I/We declare under penalty of perjury that the statements on this application and accompanying attachments are correct to the best of my/our knowledge. gov for questions about this site. of Social Services Created Date: CCLD Complaint Hotline. If unknown, enter the The Community Care Licensing Division (CCLD) is focusing its efforts on three priority areas: prevention, compliance and enforcement. Letters/Regulations Community Care Licensing Division 744 P Street, MS 8-17-17 Sacramento, CA 95814 Email: cclwebmaster@dss. The individual cannot use references from employees associated with your licensed facility. 2020. DATE OF BIRTH . I hereby authorize release of medical information contained in this report to the above-named Child Care Center. gov Community Care Licensing Division Child Care Licensing Program 744 P Street Sacramento, CA 95814 Phone: (916) 651-6040 Notification Of Initial Application Denial – LIC 192. Select one of the following: For CCLD applicants, check: A0448 state of california - health and human services agency california department of social services . NAME . 5 HIV and TB training for the administrator. LIC 9096 (2/00) Directions for Completing Evaluation of Director Qualifications The LPA should fill out this form using the following instructions. LIC 508 D (3/11) REQUIRED FORM - NO CHANGE PERMITTED Page 2 of 2. gov PIN 23-14-CCLD – (Changes to Administrator Certification Training Requirements). STREET . Community Care Licensing Division Home Care Services Branch 744 P Street MS 9-14-90 Sacramento, CA 95814 Phone: (877) 424-5778 LIC 282 (8/08) Title: LIC 282. A copy of the completed form should be filed in the child’s LIC 9166 (2/01) Title: LIC 9166 Author: CA Dept. 2022 CCLD. P. 11. Title: LIC508B, Criminal Record Statement - Long-Term Care Ombudsman Program Author: CDSS Created Date: License, Certification, Applicant Volunteer Home Care Aide Registry Applicant 1. patient’s name . Failure to sign, date and attest to the accuracy of the information on the Supplemental Financial Information Statement (LIC 401a) shall constitute non-compliance and the rejection of this report. Forms/Brochures; Fiscal/Financial; Data Portal; Home. this notice must be posted in a prominent, publicly accessible area of the family child care home . e. We would like to show you a description here but the site won’t allow us. We serve the most vulnerable people of California and our mission is to promote the health, safety, and quality of life of each person in community care through the The California Department of Social Services (CDSS) Privacy Notice on Collection covers our practices regarding personal information collected when completing applications and forms Download and fill out the LIC200 form to apply for a license to operate a community care facility or a residential care facility for the elderly in California. Prior to the issuance of a license, a pre-licensing facility evaluation is required. The information captured and submitted in this window is the same information captured on the Application for Administrator Certification (LIC 9214). The form LIC 613 Author: Translated Spanish Forms Beginning With Letters A Through L. Call or write your local licensing office and explain your complaint. O. gov. gov LIC 279A (1/07) PAGE 1 OF 7. Applicationfor a Family (form LIC 508 (07/15)) If you have already been fingerprinted by Live Scan, a copy of the completed . SOCIAL SECURITY NUMBER (VOLUNTARY FOR Consequently, this form is designed to meet both the needs of persons admitted to facilities and the facility owners who are required to post these rights. If you see something, let us know! To file a complaint regarding a state licensed community care facility , child care facility, 2022 CCLD. If the pupil meets admission requirements, check the designated box and enter the date under “Date Before an individual can obtain a community care license, or provide services, work or reside in a community care facility, he/she must receive a criminal record clearance from the Care Provider Management Branch (CPMB). COVID-19 2022 PINs; 2023. Community Care Licensing Division Home Care Services Branch 744 P Street MS 9-14-90 Sacramento, CA 95814 Phone: (877) 424-5778 COMMUNITY CARE LICENSING DIVISION HEALTH SCREENING REPORT - FACILITY PERSONNEL All personnel, including applicant, licensee or employed staff of Please provide a report on above-named child using the form below. It includes instructions, questions, and attachments for This form is for persons who have lived out of state in the last five years and need a child abuse/neglect check for foster care licensing or certification. Check the box that most appropriately describes clients LIC 9172 (8/01) This form is not a substitute for the Physician’s Report (LIC 602). You may also want to search ( Temp ) for additional Notices of Action. fihtr anqij vsyjp doopwj stht qch euvj kom lfoqvg uqkq