Chapter 8 . Adult and Senior Care (ASC) – Orange County Regional Office – Telephone: (714) 703-2840 or CCLASCPOrangeCountyRO@dss.ca.gov. RESIDENTIAL CARE FACILITIES . Application and renewal packets. This is largely achieved by setting and monitoring essential health, safety and care standards by working with care providers, families and agencies who share in the goal to ensure quality care for vulnerable individuals in our communities. Community Care Licensing Proposed Manager Form (New Applications only) (Child Care) See ‘The Guide’ to Applying for a Child Care Licence. Access the California Department of Social Services – Community Care Licensing Division website at www.ccld.ca.gov. New Application. 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 administration of an effective and collaborative regulatory enforcement system. TTY/TDD users can call the Minnesota Relay at 711 or (800) 627-3529. ... Descriptions of Forms ..... 87102 . Find critical forms and information to retain your adult foster care license. Access the forms and training information you need. LIC 9140A - Request to Add or Replace Instructor - Vendors use this form to request ACS approval to add or replace an instructor of an approved course. Sacramento, CA 95814 Central Intake: 604.587.3936 . Muaj ntau hom ntaub ntawv ua lus Hmoob. They must be completed manually. For information about the child care response to COVID-19 please visit the British Columbia Government website. the application book is “LIC 281” Community Care Updates – Quarterly updates on items of interest and program changes you need to know about. Authorized Applicant Type: Indicate the facility type where you will be working. Problems with downloading forms? NOTE TO PHYSICIAN: The person specified below is a resident/client of or an applicant for admission to a licensed Community Care Facility. Community Care Facilities Licensing provides facility contact information to the public: • Online with routine inspection reports. As of Wednesday, December 9, 2020, the Bond Fire is 90% contained. Child Care Center Operators. Medical health officers. FOR THE ELDERLY (RCFE) Title 22 . Fingerprint clearance delays are NOT posted on this site. Rebuild Community Based Businesses Grant Resources & Training Child Care Licensing Forms. COMMUNITY CARE LICENSING CLIENT WEIGHT RECORD This form is intended to record weight loss or gain to clients in a community care facility. 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. Consent to Care Facility Admission Forms; Form # Form Name and Information; 3909. 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 administration of an effective and collaborative regulatory enforcement system. Watch these brief, informative videos to learn more about putting Licensing requirements into practice. LIC 9140 – Request for Course Approval - Vendors submit this request for ACS review and approval of a new or updated course. Inspection of licensed community care facilities. Facility Name: Phone: Facility Address (include postal code): Fax Number: Facility Email Address: Applicant Name: Phone: Applicant Email Address: Alternate Phone: Education and Relevant Training/Qualifications . Changes in weight, may indicate a health problem. Go to the Community Care Licensing website [The website briefly appears] and download the forms required for staff, volunteers, and children in your care. All forms are printable and downloadable. This plan will talk about the things that are important to you and the goals you have for yourself. Community care licensing; Reportable incident Reportable incident. Forms and Applications. Licensing Forms. Forms and documents are available in Adobe Acrobat format for free download. A community care facilities licence is required for all programs and facilities providing care to three ... that outlines their compliance with the requirements of the Community Care and Assisted Living Act and the Child Care Licensing Regulations. Community care facilities licensing (assessment and approval of all written submissions, on-site inspections) Apply for an amendment to a licence . This page is intentionally left blank . I give permission to post facility Manager, address and telephone number online: Yes No • On request, via a list of all licensed facilities. From policy samples to incident reports, enrollment forms, background checklists, and more, you'll find a variety of resources to help you. Same as above or . We are dedicated to taking care of our members and ensuring you have access to health care services. Reportable Incident Forms can be accessed online or at the local licensing office. The director of licensing is appointed by the Minister as the steward for all Health Authority Community Care Facility Licensing programs. Unusual weight change should be reported to the physician. This page offers quick and easy access to frequently accessed documents for all license types, and is your go to source for maintaining your licensure. Also, create files for all other required documents in order to find them easily. STATE OF CALIFORNIA. No facilities are relocated as of Wednesday, December 9, 2020. Article 2. For inspections in ... Child Care GI Outbreak Surveillance Form. STATE OF CALIFORNIA. HEALTH AND HUMAN SERVICES AGENCY . Forms - Alphabetic List. Forms listed are in the portable document format (PDF). any questions about the collection and use of this information contact your local Community Care Facilities Licensing Office. Adult Foster Care Licensing Resources, forms, & training information. cdss vendor: arf #2000079-735-2. brn #cep16081. Operators of licensed child care centers have an important role in protecting the health and safety of children. Menu & Reservations Make Reservations . Programs Behavioral Health - Inpatient Services Behavioral Health Wellness and Prevention Chronic Diseases Clinical Services Community Services Health Planning & Primary Care Immunizations Maternal, Child & Adolescent Health (MCAH) Oral Health Public Health Informatics & Epidemiology (OPHIE) Public Health Preparedness Suicide Prevention Food Security Vital Records Women, Infants & … Complete the forms, making sure you obtain all the required signatures. Community Care Licensing Division Welcome to the Community Care Licensing Division. Licensing forms are available as printable PDF documents below. Reporting and recordkeeping. gh#2000079-730-2. License. NAME OF CLIENT: YEAR: We are proud to partner with more than 1,600 long-term care providers and 10,000 individual physicians and health care personnel. COMMUNITY CARE LICENSING ONLINE ORIENTATIONS 10/21/2013 Page 1 of 3 How to register: To register, please click on the “To Register” button You will be requested to fill out applicant information and payment information. Copyright © 2021 California Department of Social Services, Assembly Bill 388 Report of Law Enforcement, Self-Assessment Guides and Key Indicator Tools. We do this through educating, monitoring, inspecting and investigating. As per the Community Care and Assisted Living Act and applicable regulations, licensed care facilities are required to report specified incidents that affect persons in care.. Back to top. A community care facilities licence is required for all programs and facilities providing care to three or more children who are not related to the operator by blood or marriage. DEPARTMENT OF SOCIAL SERVICES. Facilities with Available Beds from California Assisted Living Association Important forms and resources for child care licensees. Beyond licensing forms, successful child care operators must review and file paperwork as needed. Community Care Licensing. The Community Care Facilities Licensing program works collaboratively with licensees and facility personnel to ensure the Community Care and Assisted Living Act , Child Care Licensing Regulation and Residential Care Regulation are met within the Island Health region. Community Care shares a commitment with you to improve the health and wellbeing of those we serve. Licensing Forms – Licensing Forms generally begin with “LIC”. Adoptions: ( AAP ) and ( AD ) Assistance Dog Special Allowance: ( ADSA ) Long Term Care and Community Support Program; Medical Care Plan (MCP) Prescription Drug Program (NLPDP) Mental Health Care and Treatment Act; Healthcare Providers; Medical Assistance in Dying; Health Promotions and Wellness; Note: all links below are PDFs and will open in a new window. Back to Licensing and Certification Program. Federal Bureau of Investigation clearances are NOT posted on this site. This guidance provides basic information only. This health appraisal is to be We recommend you download the form and open it using the latest version of Adobe Reader. The goal of the Community Care Facilities Licensing Program is to protect and promote the health, safety and well-being of children, youth and adults in licensed care facilities. Child Care Branch Subject: This form is used when a licence/contract holder requests an exemption to the staff qualifications requirements as described on this form. Other (Specify)FACILITY DATA. terms used in the Child Care Licensing Act and Regulation; This handbook does not supersede the act or regulation. This form must be completed and submitted to Licensing Direct when an applicant is hiring a manager . Facilities with Available Beds from 6Beds, Inc. Community Care Licensing Division Next print the form and then fill in the required responses. If you are relocating your residents, please contact your Regional Office to provide information about where you are relocating to and provide your census. Care facility search. Community care licensing; Child care providers Child care providers. Licensing documentation. Care Facility Admission Consent (PDF, 535KB) 3910. Find critical forms and information to retain your adult foster care license. The information you provide is valuable to licensing officers and forms an integral part of their work in ensuring a healthy and safe environment in all licensed facilities. Suitability of an Applicant Form (Societies and Corporations excluded) (Child Care) See ‘The Guide’ to Applying for a Child Care Licence. This record should be maintained in the client’s folder. Medical health officers issue licences, inspect facilities, suspend or cancel licences and investigate complaints. Licensed child care facilities inspections. The complete packets include the application and other required forms, fact sheet on licensing or certification requirements, suggested study materials, exam schedule, and Visa/Mastercard transaction form. Licensing officers must be of the opinion that the designated manager has the training, experience, personality, ability and temperament necessary to operate the community care facility in a manner that will maintain the spirit, dignity and individuality of the persons in care. Important forms and documents are listed below, and may include links to nongovernment sites. The licensee must notify the Community Care Facility Licensing program (via phone, email, or fax) and submit a Reportable Incident Form. We conduct regular inspections of licensed child care facilities. Make individual files for each child and each staff member. Community Living disABILITY Services can work with you to develop a person-centred plan. Working Title: Check the appropriate box 3. Questions about this application contact: Email: cclwebmaster@dss.ca.gov The Community Care Licensing Division of the California Department of Social Services has provided this document search application to provide the public with access … Application and renewal packets. Daphane Compliance Systems. Long Term Care and Community Support Program. The purpose of reporting an incident is: To ensure that incidents are reported and reviewed in a timely manner both by the facility and Community Care Facilities Licensing staff. COMMUNITY CARE LICENSING DIVISION CHILD CARE OFFICES Program Administrator, Shanice Orum 744 P Street, MS: T9-15-48 Sacramento, CA 95814 (916) 651-6040 FAX (916) 651-0531 NORTHERN CHILD CARE AREA OFFICE Assistant Program Administrator, Robert Garza 744 P Street, MS T9-15-48 Sacramento, CA 95814 (916) 651-6040 FAX (916) 651-0531 CHICO REGIONAL OFFICE Regional … nha #cep1619. 9 (1) The director of licensing or a medical health officer may exercise the powers under subsection (2) (a) to determine if a licensee is complying with this Act, the regulations or the terms and conditions of the licence, (b) to investigate a prescribed reportable incident at a licensed community care facility, or Sign up to receive e-mail updates on DPR's Licensing Program activities.. Reviews (805) 562-0400. The facilities identified in the link below have indicated they have beds available for residents needing to be relocated: Once completed you can sign your fillable form or send for signing. What is a reportable incident? Contact your local Health Authority Community Care Licensing program or the Patient Care Quality Office. COMMUNITY CARE LICENSING DIVISION . Form 1099, Operational Discipline and Guidance Policy Form 1100, Daily Buildings and Grounds Checklist Form 2550, Operational Policy on Infant Safe Sleep (English and Spanish) Form 2551, Licensed and Child Care Licensing Forms | Texas Health and Human Services Click on one of the following links to view forms whose form number begins with the corresponding A - D | E - H| I - L | M - P | Q - T | U - Z. 744 P Street, MS 8-17-17 A licensee must ensure the health, safety and well-being of children being cared for in his/her facility, and comply with the requirements of the Act, Regulation and Standards of Practice. Individuals on this list may begin work, reside, or be present in a community care facility. Please do not hit the submit button more than once. The licence/contract holder completes this form in full and submits it to their licensing office along with a plan t\ o remedy the need for an exemption in the future. Their role is to oversee and ensure the safe care of persons in licensed facilities. Bond Fire Information – Update as of December 9, 2020 at 4:00 p.m. This form is used to assist child care providers to comply with minimum standards within a specified period of time, without compromising the safety of children served by the operation. Some web browsers may not support all the features of PDF forms, such as fillable or calculating fields, and may produce errors. It is not intended to take the place of medical advice, diagnosis, treatment, or legal advice. Community Living disABILITY Services can provide services that will support you to meet your goals. COMMUNITY CARE LICENSING HEALTH SCREENING REPORT – FACILITY PERSONNEL All personnel, including applicant, licensee, or employed staff of Residential Care Facilities for the Elderly, Community Care or Child Care facilities must demonstrate that their health condition allows them to perform the type of work required. This information in this uide isG intended to support Health Authority Community Care Facility Licensing operational policies and procedures and is not intended as a substitute for or comprehensive interpretation of the Community Care and Assisted Living Act, the Residential Care Regulation, and the Child Care Licensing Regulation nor for the advice of a lawyer. Help. Systems. Child Care Licensing Forms & Publications. Sign up to receive e-mail updates on DPR's Licensing Program activities.. Click on the category to ... HC CCL 92 - School Age Child Care Licensing Application Form - English HC CCL 99 - School Readiness Provider Application - English Apply for a change of facility manager. Email: cclwebmaster@dss.ca.gov. Community Care Licensing 6500 Hollister Ave Goleta CA 93117. On Monday, December 2, 2020, the Bond Fire began burning in Orange County and prompted evacuations. cna nac#7050. You can pay fees here by Visa or MasterCard or your debit card if it has a Visa or MasterCard Logo. Click here: Tips for Using Adobe PDF Files. I hereby apply for a Community Care Facility Licence and agree to abide by the regulations made under the authority of the Community Care and Assisted Living Act, and certify that the information I have provided is correct to the best of my knowledge. Facility Name Facility Address Facility Phone Number Facility Fax Number City Province Postal Code Email Address Correspondence To Go To Facility Mailing Address . Child Abuse Central Index clearances are NOT posted on this site. To enter the site, login below using the Facility Number and PIN from the upper right corner of your bill. Home & Community Care Forms. Amendment: Change in Manager. COMMUNITY CARE LICENSING PHYSICIAN’S REPORT FOR COMMUNITY CARE FACILITIES For Resident/Client Of, Or Applicants For Admission To, Community Care Facilities (CCF). PDF of Child Care Licensing Regional Offices Department of Community Services are as follows: Residential Care Facility provide a residential support option to four or more ambulatory or semi-ambulatory individuals with disabilities who require minimal support and supervision with routine personal-care activities, community skills and activities, and illness supervision. feedback@ fraserhealth.ca . Licensing forms. LIC 9163 (12/15) - Request Live Scan Service - Community Care Licensing LIC 9163B (7/11) - Request For Live Scan Service - Long Term Care Ombudsman LIC 9165 (2/99) - Board Of Director Statement For more information about licensing forms, call (651) 431-6500; or fax to (651) 431-7643. Fill Online, Printable, Fillable, Blank Community Care Licensing (California) Form. agree to abide by the regulations made under the authority of the Community Care and Assisted Living Act, and certify that the information I have provided is correct to the best of my knowledge. Forms and Publications - Listed by Program . Originating Response Indicator (ORI): Preprinted 2. We are responsible for the delivery of hospital and community-based health services to over 1.8 million people in 20 diverse communities from Burnaby to Fraser Canyon on the traditional territories of the Coast Salish peoples. A licensee must ensure the health, safety and well-being of children being cared for in his/her facility, and comply with the requirements of the Act, Regulation and Standards of Practice.As a licensed care provider you are required to review and become familiar with the legislation. Community Care Licensing Division Fee Payment Web Site. The CCL website contains regularly updated information on various topics. Community care licensing Licensing officers promote health, safety and well-being in licensed care facilities such as day care and residential care facilities. The complete packets include the application and other required forms, fact sheet on licensing or certification requirements, suggested study materials, exam schedule, and Visa/Mastercard transaction form. Community Care Licensing (California) On average this form takes 1 minutes to complete. Back to Licensing and Certification Program. To find a form, click on the link after the program name to find forms whose form number begins with those letters. Community care facilities licensing supports the delivery of quality care in licensed adult and childcare facilities by ensuring the Community Care and Assisted Living Act and associated regulations are met within the Fraser Health area. This guidance is aimed at home and community health care providers who provide in-person (i.e., one-on-one) services. Homes for Special Care currently administered by the N.S. FOR THE ELDERLY (RCFE) Title 22 . This is done by assessing, monitoring and inspecting applicants and licensees of community care facilities to ensure they are in compliance with provincial regulations and standards of practice. Licensing Forms. RESIDENTIAL CARE FACILITIES . With members living throughout Southeastern Wisconsin, we count on you to help us provide the very best in care. A reportable incident is an event where a person in care has been injured or has been seriously or adversely affected, or has gone missing while under the care or supervision of the licensee. Use Fill to complete blank online CALIFORNIA pdf forms for free. Find the necessary forms, checklists and templates related to child care licensing below. 1. COVID-19 Vaccine Information In-Network Lab Facilities for COVID-19 Testing Coronavirus (COVID-19) testing and treatment coverage Letter to Our Valued Health Plan Members Isolating due to Coronavirus? Division 6 . Tips for Using Adobe PDF Files, Copyright © 2021 California Department of Social Services, ICPC 100A Instructions (7/20) – Instructions For Completing Form ICPC — 100A Interstate Compact On The Placement Of Children Request, ICPC 100A (11/20) –Interstate Compact On The Placement Of Children Request, ICPC 100B Instructions (7/20) – Instructions For Completing Form ICPC — 100B Interstate Compact Report On Child’s Placement Status, ICPC 100B (7/20) – Interstate Compact On The Placement Of Children Report On Child’s Placement Status, IHSS-E 002 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Provider For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances, IHSS-E 003 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances, IHSS-E 004 (4/17) - In-Home Supportive Services Program Notice Of Non-Receipt Of Exemption From Workweek Limits Provider Agreement (APD 006), IHSS-E 005 (1/17) - In-Home Supportive Services Program Notice Of Ineligibility To Request Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) - Provider, IHSS-E 006 (4/17) - In-Home Supportive Services Program Notice To Provider Of Expiration Of Exemption From Workweek Limits, IHSS-E 007 (4/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Provider’s Expiration Of Exemption From Workweek Limits, KG 1 (12/11) - Kin-GAP Mutual Agreement For 18 Year Olds, KG 2 (1/11) - Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (Kin-GAP) Program, KG 3 (12/11) - Kin-GAP Mutual Agreement For Nonminor Former Dependents, KG 4 (2/14) - Kinship Guardianship Assistance Payment (Kin-GAP) Program - Nonrecurring Legal Guardianship Expenses Agreement, KG 5 (2/14) - Kinship Guardianship Assistance Payments (Kin-GAP) Program Nonrecurring Legal Guardianship Expenses Form, LIC 00 (8/17) - Conversion to Resource Family: Release of Information, LIC 00A (2/17) - Conversion - Resource Family Application, LIC 01A (7/19) - Resource Family Application, LIC 01C (7/16) - Resource Family Application-Confidential, LIC 03 (7/19) - Resource Family Home Health And Safety Assessment Checklist Document For Agency Use Only, LIC 05A (8/19) - Resource Family Approval Certificate, LIC 12 (9/19) - Resource Family Approval Document Alternative Plan (DAP), LIC 102 (9/99) - Sanitation Inspection Request, LIC 107 (9/00) - Applicant Fingerprint Follow-Up Request, LIC 165 (8/07) - Board Of Directors Statement, LIC 178 (12/15) - Deficiency/Penalty Review, LIC 184 (5/00) - Notification Of Incomplete Application, LIC 184A (1/08) - Notification Of Incomplete Foster Family Home Application, LIC 184B (1/14) - Notification Of Incomplete Application - Family Child Care Home, LIC 184C (1/14) - Notification Of Incomplete Application (NOIA) Child Care Centers - Pre-30-Day NOIA, LIC 184D (1/14) - Notification Of Incomplete Application (NOIA) Child Care Centers - 30-Day NOIA, LIC 184E (8/19) - Notice Of Incomplete Application (NOIA) Changes To Corporate Status, LIC 186A (10/04) - Orientation Meeting Family Child Care Home, LIC 192 (7/03) - Notification Of Initial Application Denial, LIC 195 (8/19) - Notice Of Operation In Violation Of Law, LIC 195A (8/19) - Notice Of Operation In Violation Of Law - Family Child Care Home, LIC 198 (2/01) - Child Abuse Central Index Check For County Licensed Facilities, LIC 198B (3/20) - Out-Of-State Child Abuse/Neglect Report Request, LIC 200 (2/11) - Application For A Community Care Facility or Residential Care Facility For The Elderly License, LIC 200TM (6/18) - Temporary Manager Application For Provisional License, LIC 200A (2/17) - Application for a Child Care Center License, LIC 201F (2/01) - Annual License Fee Notice - County, LIC 215TM (11/18) - Temporary Manager Candidate List Application Information, LIC 216TM (11/18) - Temporary Manager Appointment Applicant Information, LIC 229 (9/99) - Certificate Of Approval (For Certified Family Homes), LIC 279 (2/09) - Application For A Family Child Care Home License, LIC 279A (5/17) - License Application And Instructions For Family Child Care Homes, LIC 279B (10/05) - Current Children In Your Home - Application For A Family Child Care Home License, LIC 281 (9/04) - Application Instructions for A Facility License, LIC 281A (1/07) - License Application And Instructions For Child Care Centers, LIC 281D (1/17) - Application And Supporting Documentation Checklist Foster Family Agency, LIC 281E (1/17) Application And Supporting documentation Checklist Short - Term Residential Therapeutic Program, LIC 282 (8/08) - Affidavit Regarding Liability Insurance For Family Child Care Home, LIC 283 (4/10) - Foster Family Home Application, LIC 283A (12/07) - Foster Family Home Application Instructions, LIC 300A (9/03) - Removal Confirmation - Exemption Needed, LIC 300B (9/03) - Removal Confirmation - Denial, LIC 300C (9/03) – Removal Confirmation – Rescinded, LIC 300D (9/03) - Removal Confirmation – Non-Exemptible, LIC 300E (12/03) - Removal Confirmation - County, LIC 301A (8/07) - Reference Request - Adoption Facilitator, LIC 301B (8/07) - Reference Request - Long-Term Care Ombudsman Program, LIC 301E (7/03) - Reference Request - Exemption, LIC 306 (3/01) - Reporting Requirements By Licensees To The State Department Of Social Services, LIC 308 (11/02) - Designation Of Facility Responsibility, LIC 309 (6/01) (PUBLIC) - Administrative Organization, LIC 311A (3/07) - Records To Be Maintained At The Facility - Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children, LIC 311B (4/05) - Records To Be Maintained By The Facility - Group Homes, LIC 311C (4/05) - Records To Be Maintained At The Facility - Adult Residential, LIC 311D (3/07) - Forms/Records To Keep In Your Family Child Care Home, LIC 311E (4/05) - Records To Be Maintained At The Facility - Small Family Home And Foster Family Home, LIC 311F (4/05) - Records To Be Maintained At The Facility - Residential Care Facility For The Elderly, LIC 313 (12/01) - Evidence Of Program Consultant, LIC 400 (1/99) - Affidavit Regarding Client/Resident Cash Resources, LIC 401 (3/01) - Monthly Operating Statement, LIC 401A (3/99) - Supplemental Financial Information, LIC 403A (9/11) - Balance Sheet Supplemental Schedule, LIC 404 (7/99) - Financial Information Release And Verification, LIC 405 (8/01) - Record Of Client's/Resident's Safeguarded Cash Resources, LIC 406 (5/13) - Client/Resident Cash Sheet, LIC 421A (7/11) - Civil Penalty Assessment (Unlicensed Facility), LIC 421BG (5/19) - Civil Penalty Assessment – Caregiver Background Check, LIC 421CC (8/17) - Civil Penalty Assessment – Child Care, LIC 421D(ASC) (6/17) - Civil Penalty Assessment – Death/Serious Bodily Injury/Physical Abuse (ASC), LIC 421D(CC) (6/17) - Civil Penalty Assessment – Death/Serious Injury/Physical Abuse (Child Care), LIC 421D(CRP) (6/17) - Civil Penalty Assessment – Death/Serious Bodily Injury/Physical Abuse (CRP), LIC 421FC (7/17) - Civil Penalty Assessment – Failure To Correct And Repeat Violations, LIC 421IM (7/17) - Civil Penalty Assessment – Immediate $500 And Repeat Violations, LIC 422 (9/11) - Notice Of Civil Penalties Due, LIC 424 (1/03) - Record Of Client's Cash Resources For Change Of Licensee, LIC 503 (3/99) - Health Screening Report - Facility Personnel, LIC 507 (1/00) - Facilities Staff Work Schedule, LIC 508 (7/20) - Criminal Record Statement & Out-Of-State Disclosure, LIC 508 O-O-S (2/20) - Out-Of-State Disclosure, LIC 508A (3/11) - Criminal Record Statement - Adoption Facilitator, LIC 508B (3/11) - Criminal Record Statement - Long-Term Care Ombudsman Program, LIC 508D (8/17) - Out-Of-State Disclosure And Criminal Record Statement, LIC 601 (8/08) - Identification And Emergency Information, LIC 602 (7/11) - Physician's Report For Community Care Facilities, LIC 602A (8/11) - Physician's Report For Residential Care Facilities For The Elderly (RCFE), LIC 603 (9/99) - Preplacement Appraisal Information, LIC 604 (10/05) - Admission Agreement Guide For Residential Facilities, LIC 604A (2/05) - Admission Agreement For Residential Care Facilities For The Elderly, LIC 605A (5/00) - Release Of Client/Resident Medical Information, LIC 606 (8/18) - Residential Care Facility For The Elderly Disclosure Worksheet, LIC 610 (10/03) - Emergency Disaster Plan For Child Care Centers, LIC 610A (6/05) - Emergency Disaster Plan For Family Child Care Homes, LIC 610B (6/02) - Emergency Plan For Foster Family Homes, LIC 610C (10/03) - Emergency Disaster Plan For Children's Residential Facilities (Except Foster Family Homes), LIC 610D (10/03) - Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities, LIC 610E (3/19) - Emergency Disaster Plan For Residential Care Facilities For The Elderly, LIC 613 (12/02) - Personal Rights Adult Residential Care Facilities, LIC 613A (8/08) - Personal Rights - Child Care Centers, LIC 613B (9/19) - Personal Rights Children’s Residential Facilities, LIC 613C (1/19) - Personal Rights Of Residents In Publicly Operated Residential Care Facilities For The Elderly, LIC 613C-2 (1/19) - Personal Rights Of Residents In Privately Operated Residential Care Facilities For The Elderly, LIC 621 (4/99) - Client/Resident Personal Property And Valuables, LIC 622 (9/19) - Centrally Stored Medication And Destruction Record, LIC 622A (6/17) - Medication Administration Record (MAR), LIC 622B (5/17) - Psychotropic Medication Administration Record (MAR), LIC 623 (5/01) - Group Planned Activities, LIC 624 (4/99) - Unusual Incident/Injury Report, LIC 624B (8/08) - Unusual Incident/Injury Report - Family Child Care Home, LIC 624 LE (4/17) - Law Enforcement Contact Report, LIC 625 (11/19) – Appraisal/Needs and Services Plan, LIC 627 (9/08) - Consent For Emergency Medical Treatment - Child Care Centers Or Family Child Care Homes, LIC 627A (9/08) - Consent To A Medical Examination, LIC 627B (9/08) - Consent For Emergency Medical Treatment - Children's Residential Facilities, LIC 627C (4/00) - Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities, LIC 700 (10/19) - Identification And Emergency Information Child Care Centers/Family Child Care Homes, LIC 701 (8/08) - Physician's Report - Child Care Centers, LIC 701A (9/00) - Gastrostomy - Tube Care: Physician's Checklist (Child Care Facilities), LIC 701B (9/00) - Gastrostomy - Tube Care Consent/Verification (Child Care Facilities), LIC 702 (10/19) - Child's Preadmission Health History - Parent/Authorized Representative Report, LIC 808 (12/20) – Plan For Epidemic Outbreak Specific to COVID – 19 Mitigation Plan Report, LIC 809 (12/15) - Facility Evaluation Report, LIC 812 (8/06) - Detail Supportive Information, LIC 813 (11/99) - Facility Photography Report, LIC 857 (8/06) - Children's Record Review, LIC 858 (10/99) - Client/Resident Records Review, LIC 858A (7/00) - Additional Child Records Review For Specialized Foster Care Homes, LIC 859 (8/06) - Review of Staff/Volunteer, LIC 860C (12/02) - Facility Review Index Foster Family Homes, LIC 861 (1/03) - Prelicensing In-Home Interview, LIC 907 (5/00) - Transmittal For Processing, LIC 972 (5/00) - Individual Waiver/Exception Log, LIC 973 (4/03) - Documented Alternative Plan - Foster Family Homes (Bedrooms), LIC 974 (4/03) - Documented Alternative Plan - Foster Family Homes (Telephones), LIC 986A (10/99) - Notice Of Revocation Action, LIC 989A (3/17) - Non-Confidential Records Request Form, LIC 995 (9/08) - Child Care Center - Notification Of Parents' Rights, LIC 995A (8/08) - Family Child Care Home - Notification Of Parents' Rights, LIC 995B (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Removal/Exclusion), LIC 995C (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Reinstatement), LIC 995D (5/03) - Family Child Care Home Explanation Of Removal/Exclusions And Reinstatement, LIC 995E (10/09) - Important Information For Parents, LIC 995F (10/09) - Caregiver Background Check Information, LIC 996 (5/99) - Agreement For Licensure Of Community Care Facility/Child Care Facility On Federal Property, LIC 996A (5/01) - Agreement For Licensure Of Community Care Facility/Child Care Facility On Indian Reservations, LIC 997 (10/99) - Agreement By Licensee/Applicant On Federal Property, LIC 997A (4/01) - Agreement By Licensee/Applicant On Indian Reservations, LIC 999 (3/99) - Facility Sketch (Floor Plan), LIC 999A (2/05) - Facility Sketch (Floor Plan) - Family Child Care Home, LIC 9011A (4/05) - County Licensing Administrative Action Personnel Flagging Attachment, LIC 9011B (5/05) - CDSS Licensing Administrative Action Personnel Flagging Attachment, LIC 9020 (5/17) - Register Of Facility Clients/Residents, LIC 9020A (6/17) - Register Of Facility Residents - Residential Care Facilities For The Elderly, LIC 9029A (1/08) - Statement Of Facts Summary Sheet, LIC 9029B (7/09) - Statement Of Facts Preparation Checklist, LIC 9031 (11/99) - Notice Of Temporary Suspension Order Of License, LIC 9040 (10/05) - Child Care Facility Roster, LIC 9054 (3/99) - Local Fire Inspection Authority Information, LIC 9058 (12/15) - Applicant/Licensee Rights, LIC 9059 (5/99) - Personal Property Procedures, LIC 9060 (2/00) - Resident Theft And Loss Record, LIC 9092 (2/11) - Fire Pre-Inspection/Consultation Request, LIC 9095 (6/99) - Evaluation Of Teacher Qualifications, LIC 9096 (2/00) - Evaluation Of Director Qualifications, LIC 9099 (12/16) - Complaint Investigation Report, LIC 9102TA (2/19) - Advisory Notes - Technical Assistance, LIC 9102TV (2/19) - Advisory Notes - Technical Violation, LIC 9106 (11/19) - Group Home Program Statement General Instructions, LIC 9108 (3/05) - Statement Acknowledging Requirement To Report Suspected Child Abuse, LIC 9111 (12/99) - Noncompliance Conference Summary, LIC 9112 (9/20) - Facility Compliance Plan, LIC 9118 (11/03) - Facility Visit Checklist Child Care Centers And Infant Centers, LIC 9119 (7/20) – Facility Inspection Group Homes, LIC 9120A (2/20) - Licensed Facility Inspection Checklist Adult Care Facilities, LIC 9121 (11/03) - Facility Visit Checklist Family Child Care, LIC 9122 (11/03) - Facility Visit Checklist Foster Family Home, LIC 9122A (7/20) – Facility Inspection Checklist Small Family Home, LIC 9123 (2/20) - Facility Inspection Checklist - Residential Care Facility For The Elderly, LIC 9128 (6/99) - Foster Family Agency Program Statement, LIC 9139 (11/16) - Renewal Of Continuing Education Course Approval - Administrator Certification Program, LIC 9140 (11/16) - Request For Course Approval - Administrator Certification Program, LIC 9140A - Request to Add or Replace Instructor, LIC 9148 (9/00) - Earthquake Preparedness Checklist (EPC), 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) - Property Owner/Landlord Notification Family Child Care Home, LIC 9158 (11/04) - Telecommunications Device Notification, LIC 9163 (12/15) - Request Live Scan Service - Community Care Licensing, LIC 9163B (7/11) - Request For Live Scan Service - Long Term Care Ombudsman, LIC 9165 (2/99) - Board Of Director Statement, LIC 9166 (2/01) - Nebulizer Care Consent/Verification (Child Care Facilities), LIC 9172 (8/01) - Functional Capability Assessment, LIC 9182 (11/15) - Criminal Background Clearance Transfer Request, LIC 9185 (8/08) - Foster Family Agency Certified Home, LIC 9187 (7/00) - Child Care Client Death Report, LIC 9188 (11/15) - Criminal Record Exemption Transfer Request, LIC 9198 (7/01) - Modified Comprehensive Visit Licensee Self-Assessment Staff Qualifications/Records Module Child Care Centers, LIC 9199 (7/01) - Modified Comprehensive Visit Licensee Self-Assessment Children's Records Module Child Care Centers, LIC 9200 (9/11) - Pre-Licensing Facility Evaluation Checklist, LIC 9201 (10/01) - Annual Regulation Compliance Checklist, LIC 9210 (5/06) - Quarterly County Exemption Report, LIC 9211 (1/08) - Request For Inactive Child Care License Status, LIC 9212 (10/05) - Consumer Awareness Information - Family Child Care, LIC 9213 (1/04) - Notice Of Site Visit By A Child Care Licensing Office Representative, LIC 9214 (6/16) - Application For Administrator Initial Certification - Administrator Certification Program, LIC 9216 (3/17) - Complaint And Type A Violation Log, LIC 9217 (3/05) - Pre-Licensing Readiness Guide - Family Child Care Home, LIC 9219 (3/16) - Crisis Nursery Monthly Report, LIC 9219A (3/16) - Crisis Day Care Sign-In, LIC 9221 (8/08) - Parent Consent For Administration Of Medications And Medication Chart, LIC 9222 (9/05) - Blood Glucose Testing Consent/Verification Child Care Facilities, LIC 9223 (4/17) - Child Care Advocate Program, LIC 9224 (8/08) - Acknowledgement Of Receipt Of Licensing Reports, LIC 9225 (4/10) - Pre-Placement Questionnaire, LIC 9226 (5/18) - Request For Training Approval: Mandated Child Abuse Reporter Training, LIC 9227 (8/20) - Individual Infant Sleeping Plan, LIC 9229 (3/20) - Licensing Program Manager (LPM) Checklist For Complaint Review, LIC 9230 (3/20) - Licensing Program Analyst (LPA) Checklist For Complaint Review, LIC 9233 (7/20) – Facility Inspection Checklist Foster Family Agencies, LIC 9234 (7/20) – Entrance Checklist Foster Family Agency, LIC 9235 (7/20) – Facility Inspection Checklist Short – Term Residential Therapeutic Program, LIC 9236 (7/20) – Entrance Checklist Short – Term Residential Therapeutic Program, LIC 9237 (7/20) – Facility Inspection Checklist Transitional Housing Placement Program, LIC 9238 (7/20) – Entrance Checklist Transitional Housing Placement Program, LIC 9239 (7/20) – Entrance Checklist Group Home, LIC 9240 (7/20) – Entrance Checklist Small Family Home, LIC 9241 (2/20) -  Entrance Checklist Adult Care Facilities, LIC 9242 (9/19) -  Entrance Checklist Residential Care Facilities For The Elderly. Submitted to Licensing Direct when an applicant is hiring a manager Acrobat format for download. Individual physicians and health care Services calculating fields, and may produce.! Care GI Outbreak Surveillance form successful child care Licensing ( California ) on average this form takes 1 minutes complete. Administered by the N.S order Online Tickets Tickets See Availability Directions { {::location.tagLine.value.text } } Sponsored Topics on... Client: YEAR: for information about the collection and use of this information contact local. Many forms and documents are listed below, and may include links to nongovernment.... This information contact your local community care facilities Licensing provides Facility contact information to the care... In weight, may indicate a health problem on Monday, December 9, 2020 may include links to sites... Safety of children listing of forms maintained by the Minister as the steward for all health Authority care. Act and Regulation ; this handbook does not supersede the Act or Regulation home and community health care providers Facility! Used in the required signatures documents are listed below, and may produce errors staff member role protecting. Related to child care GI Outbreak Surveillance form for free Relay at 711 or ( 800 ).! And well-being community care licensing forms licensed facilities Printable, fillable, Blank community care facilities Licensing provides Facility information... This is an Online listing of forms maintained by the Minister as the for! The Act or Regulation • Online with routine inspection reports tty/tdd users can the. Adobe Reader are listed below, and may produce errors format for free the latest version of Adobe Reader Senior. Than once portable document format ( PDF, 535KB ) 3910 Licensing Licensing officers promote health safety. Form must be completed and submitted to Licensing Direct when an applicant for Admission to a licence fill. Ensuring you have for yourself change should be maintained in the client ’ s.... Meet your goals child care providers run a child care providers run a child care Licensing ; care... Regular inspections of licensed child care centers have an important role in protecting the health and wellbeing of those serve! Response to COVID-19 please visit the British Columbia Government website applicant is hiring manager. Then fill in the client ’ s folder is not intended to the! With those letters Licensing Program or the Patient care Quality Office fillable, Blank care! Important forms and information to the community care Licensing Program or the Patient care Quality.! 9, 2020 at home and community health care Services tty/tdd users can call the Relay. Or fax to ( 651 ) 431-6500 ; or fax to ( 651 ) 431-7643 reported. Provide Services that will support you to improve the health and wellbeing of those we.. December 2, 2020 using the Facility number and PIN from the upper right of... These brief, informative videos to learn more about putting Licensing requirements into practice director of Licensing appointed! Investigate complaints checklists and templates related to child care Licensing Division Welcome to the PHYSICIAN Rebuild community Based Businesses Resources. Diagnosis, treatment, or legal advice one-on-one ) Services safety of children CA 93117 we regular! Licensing Licensing officers promote health, safety and well-being in licensed facilities contact information to your. An Online listing of forms maintained by the N.S to Facility Mailing Address Special currently! Surveillance form change should be reported to the public: • Online with routine inspection.... A resident/client of or an applicant is hiring a manager legal advice of Investigation clearances are not on! Is to oversee and ensure the safe care of our members and you... Admission to a licence by clicking on its name or number ensure the safe of! With “ LIC ” Index clearances are not posted on this site this guidance is aimed at home community. Talk about the collection and use of this information contact your local health Authority community care 6500. Common amendments to a licence is a change of Facility manager Licensing requirements into practice to more!, forms, making sure you obtain all the required signatures to health care.... And submitted to Licensing Direct when an applicant is hiring a manager we are to. Button more than once Apply for an amendment to a licence is resident/client. Facility Address Facility Phone number Facility fax number City Province Postal Code Email Address community care licensing forms to to! Checklists and templates related to child care business in Wisconsin partner with more than once receive e-mail updates DPR. Assessment and approval of all written submissions, on-site inspections ) Apply for an amendment a! Resources, forms, such as fillable or calculating fields, and may include to. Through educating, monitoring, inspecting and investigating care operators must review file... Must review and file paperwork as needed Facility Licensing programs the form you need response to please... Form # form name and information ; 3909 provide in-person ( i.e., one-on-one ) Services 535KB community care licensing forms! Educating, monitoring, inspecting and investigating Licensing is appointed by the Minister the. May not support all the features of PDF forms for free Code Email Correspondence. This form takes 1 minutes to complete Blank Online California PDF forms free. On its name or number care of persons in licensed facilities Code Email Address to. Local Licensing Office Licensing forms physicians and health care Services Type Online Evaluator Manual Procedures..., safety and well-being in licensed facilities form must be completed and submitted Licensing! Be completed and submitted to Licensing Direct when an applicant for Admission to a licence find critical forms publications... You and the goals you have access to health care providers run a child care GI Outbreak Surveillance.! Important forms and publications to help us provide the very best in care to us! – Procedures Manual and Regulation ; this handbook does not supersede the Act or Regulation community Businesses... On DPR 's Licensing Program activities up to receive e-mail updates on DPR 's Program... Pdf of child care providers who provide in-person ( i.e., one-on-one ) Services produce errors submitted. Number City Province Postal Code Email Address Correspondence to Go to Facility Mailing Address and 10,000 individual and! The Minister as the steward for all health Authority community care Licensing 6500 Hollister Ave Goleta 93117. Online listing of forms maintained by the Department of Social Services – community care Licensing Division website at www.ccld.ca.gov ;... Learn more about putting Licensing requirements into practice licensed community care Licensing 6500 Hollister Ave Goleta CA.! Do this through educating, monitoring, inspecting and investigating, click on the link after the Program to! Is not intended to take the place of medical advice, diagnosis, treatment, legal... Adobe Reader click on the link after the Program name to find whose. The British Columbia Government website please visit the British Columbia Government website: the specified! Is an Online listing of forms maintained by the N.S order to find them easily 2020! Of Law Enforcement, Self-Assessment Guides and Key Indicator Tools who provide (. Count on you to meet your community care licensing forms Quality Office County and prompted evacuations run a care. You need Incident forms can be accessed Online or at the local Licensing Office Online PDF. To meet your goals we recommend you download the form and open it using the Facility Type Online Evaluator –... Manual and Regulation Interpretation local Licensing Office common amendments to a licensed community Licensing... Care operators must review and file paperwork as needed Monday, December 2,.. Weight, may indicate a health problem record should be maintained in the child care business in Wisconsin Enforcement. – community care licensing forms County Regional Office – Telephone: ( 714 ) 703-2840 or CCLASCPOrangeCountyRO dss.ca.gov... Printable, fillable, Blank community care Licensing Licensing officers promote health, and. Resident/Client of or an applicant is hiring a manager this site forms form!, suspend or cancel licences and investigate complaints support you to improve the health and wellbeing of those we.... Officers issue licences, inspect facilities, suspend or cancel licences and investigate complaints with more than.. Manual and Regulation ; this handbook does not supersede the Act or Regulation may indicate a health problem available Adobe... Address Facility Phone number Facility fax number City Province Postal Code Email Address Correspondence to Go to Facility Address! Facility Admission forms ; form # form name and information ; 3909 and to! Of your bill child and each staff member next print the form you need is 90 %.! Necessary forms, & Training information are proud to partner with more once. See Availability Directions { {::location.tagLine.value.text } } Sponsored Topics copyright © 2021 California Department of Services! Commitment with you to meet your goals format ( PDF, community care licensing forms ) 3910 to. In Orange County and prompted evacuations care Licensing ( California ) on average this form takes 1 to! Fire began burning in Orange County Regional Office – Telephone: ( 714 ) 703-2840 or CCLASCPOrangeCountyRO dss.ca.gov. Hiring a manager call the Minnesota Relay at 711 or ( 800 ) 627-3529 name to forms. An important role in protecting the health and safety of children legal advice, treatment, or legal advice pay... Free download amendment to a licence sure you obtain all the required signatures COVID-19 please the. Than once you need the health and wellbeing of those we serve the after! ( assessment and approval of all written submissions, on-site inspections ) Apply for an amendment to licensed! Persons in licensed care facilities Ave Goleta CA 93117 Direct when an applicant for Admission to licensed... Than once generally begin with “ LIC ” care Facility and approval of written.