community care licensing forms

released, or otherwise made publicly available shall disclose your name as a complainant. Please call with any questions or to connect with a Licensing staff member. [opens in a new window] IHPP Referral Form for Authorization. 195 North 1950 West If you do not have Adobe Reader, you can download this FREE software from the Adobe website. Get started with our no-obligation trial. Adult Care. We are pleased to announce Child Care Licensing is now part of the newly consolidated Department of Health and Human Services (DHHS). Playground Inspection Certification Summary CCL-5047 Word, Incident Report CCL-4605 - PDF Application (Lic 200) Applicant Information (Lic 215) Designation Of Administrative Responsibility (Lic 308) Administrative Organization (Lic 309) Affidavit Regarding Client Cash Resources (Lic 400) Surety Bond (Lic 402) Monthly Operating Statement (Lic 401) Have questions about licensing and vendorization or about the program designs? (July, 2022), Licenses, Certificates, Approvals, & Exemptions, Abuse/Neglect of Seniors and Adults with Disabilities. English. For every single segment, fill out the content requested by the software. A physical address must be provided to investigate your concerns. Child Care Licensing Program Office 744 P Street, MS: T9-15-48 Sacramento, CA 95814 Phone (916) 651-6040 Fax (916) 651-0531 Northern Regional Offices Assistant Program Administrator, Robert Garza (916) 651-6040, Alt. Toll Free: 1-866-937-2783. Salt Lake City, Ut 84116, Child Care Licensing Contact Info Group Homes. 2021 January-June Statewide Nevada Child Care Licensing Report; Forms - Background. Multi-Agency State Office Building Child Care Community Organizations Human Services Organizations. Call: 988 (Press 1), U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420. 1-800-273-TALK(8255) 3. Designation Of Administrative Responsibility (Lic 308), Affidavit Regarding Client Cash Resources (Lic 400), Supplemental Financial Information (Lic 401a), Balance Sheet Supplemental Schedule (Lic 403a), Financial Information Release & Verification (Lic404). Report Fraud & Abuse. This is to verify the identity of the covered individual and to ensure all covered individuals passed the background check. Forms and documents are available in Adobe Acrobat format for free download. Select option 1 for Claims and Eligibility. Let Us No to submit a complaint. Take two copies of this form with you the day you are fingerprinted. Fields are being added to your document to make it really easy to fill, send and sign this PDF. Then mail the document to the appropriate Office of Child Care Regional Licensing Office. See our locations servicing Fresno, Merced, Tulare/Kings, Madera, and Mariposa Counties. Provider Forms. They must be completed manually. LIC 700. Set a password to access your documents anytime, You seem to be using an unsupported browser. | A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z |, Admission Agreement For Residential Care Facilities For The Elderly LIC 604A, Admission Agreement Guide For Residential Facilities LIC 604, Affidavit Regarding Client/Resident Cash Resources LIC 400, Affidavit Regarding Liability Insurance For Family Child Care Home LIC 282, Annual License Fee Notice County LIC 201F, Applicant Fingerprint Follow-Up Request LIC 107, Application for a Child Care Center License LIC 200A, Application For A Community Care Facility or Residential Care Facility For The Elderly License LIC 200, Application For A Family Child Care Home License LIC 279, Application Instructions for A Facility License LIC 281, Appraisal/Needs And Services Plan LIC 625, Balance Sheet Supplemental Schedule LIC 403A, Centrally Stored Medication And Destruction Record LIC 622, Certificate Of Approval (For Certified Family Homes) LIC 229, Child Abuse Central Index Check For County Licensed Facilities -LIC 198, Child Abuse Central Index Check For State Licensed Facilities LIC 198A, Childs Preadmission Health History Parents Report LIC 702, Civil Penalty Assessment Immediate LIC 421B, Civil Penalty Assessment (Unlicensed Facility) LIC 421A, Civil Penalty Ledger Payment, Reduction, Or Waiver Record LIC 422A, Client/Resident Personal Property And Valuables LIC 621, Confidential Report Not Subject To Public Disclosure Report Of Suspected Dependent Adult/Elder Abuse SOC 341, Consent For Emergency Medical Treatment Child Care Centers Or Family Child Care Homes LIC 627, Consent For Emergency Medical Treatment Childrens Residential Facilities LIC 627B, Consent For Emergency Medical Treatment Adult And Elderly Residential Facilities LIC 627C, Consent To A Medical Examination LIC 627A, Criminal Background Clearance Transfer Request LIC 9182, Criminal Record Statement Adoption Facilitator LIC 508A, Criminal Record Statement Long-Term Ombudsman Program LIC 508B, Current Children In Your Home Application For A Family Child Care Home License LIC 279B, Designation Of Facility Responsibility LIC 308, Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities LIC 610D, Emergency Disaster Plan For Child Care Centers LIC 610, Emergency Disaster Plan For Childrens Residential Facilities (Except Foster Family Homes) LIC 610C, Emergency Disaster Plan For Family Child Care Homes LIC 610A, Emergency Disaster Plan For Residential Care Facilities For The Elderly LIC 610E, Emergency Plan For Foster Family Homes LIC 610B, Financial Information Release And Verification LIC 404, Forms/Records To Keep In Your Family Child Care Home LIC 311D, Foster Family Home Application Instructions LIC 283A, Gastrostomy Tube Care: Physicians Checklist (Child Care Facilities) LIC 701A, Gastrostomy Tube Care Consent/Verification (Child Care Facilities) LIC 701B, Health Screening Report Facility Personnel LIC 503, Identification And Emergency Information LIC 601, Identification And Emergency Information Child Care Centers/Family Child Care Homes LIC 700, License Application And Instructions For Child Care Centers LIC 281A, License Application And Instructions For Family Child Care Homes LIC 279A, Notice Of Operation In Violation Of Law LIC 195, Notice Of Operation In Violation Of Law Family Child Care Home LIC 195A, Notification Of Incomplete Application LIC 184, Notification Of Incomplete Foster Family Home Application LIC 184A, Notification Of Initial Application Denial LIC 192, Orientation Meeting Family Child Care Home LIC 186A, Out-Of-State Child Abuse/Neglect Report Request LIC 198B, Out-Of-State Disclosure And Criminal Record Statement LIC 508D, Personal Rights Child Care Centers LIC 613A, Personal Rights Childrens Residential Facilities LIC 613B, Personal Rights Adult Residential Care Facilities LIC 613, Personal Rights Residential Care Facilities for The Elderly (Publicly Operated) LIC 613C, Personal Rights Residential Care Facilities for The Elderly (Privately Operated) LIC 613C-2, Physicians Report Child Care Centers LIC 701, Physicians Report For Community Care Facilities LIC 602, Physicians Report For Residential Care Facilities For The Elderly (RCFE) LIC 602A, Pre-placement Appraisal Information LIC 603, Record Of Clients Cash Resources For Change Of Licensee LIC 424, Record Of Clients/Residents Safeguarded Cash Resources LIC 405, Records To Be Maintained At The Facility Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children LIC 311A, Records To Be Maintained At The Facility Adult Residential LIC 311C, Records To Be Maintained At The Facility Small Family Home And Foster Family Home LIC 311E, Records To Be Maintained At The Facility Residential Care Facility For The Elderly LIC 311F, Records To Be Maintained By The Facility Group Homes LIC 311B, Reference Request Adoption Facilitator LIC 301A, Reference Request Long-Term Care Ombudsman Program LIC 301B, Release Of Client/Resident Medical Information LIC 605A, Removal Confirmation Exemption Needed LIC 300A, Removal Confirmation Non-Exemptible LIC 300D, Removal Confirmation Rescinded LIC 300C, Reporting Requirements By Licensees To The State Department Of Social Services LIC 306, Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders SOC 341a, Supplemental Financial Information LIC 401A, Unusual Incident/Injury Report Family Child Care Home LIC 624B, Your Right To Make Decisions About Medical Treatment PUB 325, If you don't see what you're looking for, please give us a call at 530-894-2114. }else{ Title 22 Regulations - Sorted by Facility Type Online Evaluator Manual - Procedures manual and Regulation Interpretation. General Licensing Requirements. Sexual Violence Crisis Line You can pay fees here with a Visa, MasterCard, or with your debit card, if it has a Visa or MasterCard Logo. Child Care License Designee CCL-5003 - Word, Certification of School Building Fire Safety Provisions CCL-5043 - PDF Please switch auto forms mode to off. Please visit the VA Forms page for other forms not listed here or to search for a specific VA form. Application for a. Sort:Default. You will need to contact your local licensing office for all other clearance verifications. Applicant Fingerprint Follow-Up Request - LIC 107. If known, include the name of the perpetrator, The Division of Licensing and Background Checks is comprised of the Office of Licensing and the Office of Background Processing. Small Family Homes. Send to someone else to fill in and sign. Final decisions have not yet been made and contacting CCL staff may delay that decision making process. Next print the form and then fill in the required responses. We license Foster Homes, Child Care Facilities, Human Services Programs, and Health Facilities, utilizing rules established with community support, to protect the dependent and vulnerable citizens of Utah. Welcome to Utah's Child Care Licensing. Family and Group Home Increased Capacity and Ratio Request - Word Version, Family and Group Home Increased Capacity and Ratio Request PDF Version, Waiver for Decreasing Capacity Fillable Word Version, Waiver for Decreasing Capacity PDF Version, Request of Child Care Forms CCL-2021 PDF, Request of Child Care Forms CCL-2021 Word, Child Care Licensing Information Request - CCL 001 -PDF, Child Care Licensing Information Request - CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - PDF, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word, Background Check and Fingerprinting Information, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - PDF, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - Word, Medical Clearance Request - CCL-3704 - PDF, Medical Clearance Request - CCL-3704 - Word, Child Information Record - CCL-3731 - PDF, Child Information Record - CCL-3731 - Word, Child Information Record - CCL 3731-AR (Arabic), Documento de Informacin del Nio Estado de Michigan - CCL-3731-SP, Zoning Approval for Group Child Care Homes - CCL-3748 - PDF, Zoning Approval for Group Child Care Homes - CCL-3748 - Word, Declaracin/Recibo de Nios en Cuidado - CCL-3900-SP, Child in Care Statement/Receipt - CCL-3900 - PDF, Child in Care Statement/Receipt - CCL-3900 - Word, Training Record Family/Group Child Care Homes - CCL-4590 PDF, Training Record Family/Group Child Care Homes - CCL-4590 - Word, Assistant Caregiver Certifications - CCL-4595 - PDF, Assistant Caregiver Certifications - CCL-4595 - Word, Home Fire and Tornado Drill Record - CCL-4593 - PDF, Home Fire and Tornado Drill Record - CCL - 4593 - Word, Licensing Notebook Summary Sheet - CCL-5052 - PDF, Licensing Notebook Summary Sheet - CCL-5052 - Word, Request for Modification of the Terms of the License - CCL-5054 - PDF, Request for Modification of the Terms of the License - CCL-5054 - Word, Variance Request Early Childhood Program Director Fillable Word Version, Variance Request Early Childhood Program Director PDF Version, Variance Request School-Age Program Director Fillable Word Version, Variance Request School-Age Program Director PDF Version, Variance Request Lead Caregiver Fillable Word Version, Variance Request Lead Caregiver PDF Version, Child Care Licensing Information Request - BCHS-CCL 001 - PDF, Child Care Licensing Information Request - BCHS-CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word. We provide your child with an unsurpassed learning. This document has been signed by all parties. Providers will then have to submit another background check form and fingerprints if they still want the covered individual's background check to be processed. FAMILY CHILD CARE HOME ADDENDUM TO NOTIFICATION OF (California), EARTHQUAKE PREPAREDNESS CHECKLIST (EPC) * (California), FAMILY CHILD CARE HOME OTIFICATION OF PARENTS RIGHTS (California), EMERGENCY DISASTER PLAN FOR FAMILY CHILD CARE HOMES (California), ADVANCE HEALTH CARE DIRECTIVE FORM (California), FORM MUST BE SIGNED. Crisis Line & Mobile Outreach Team If you change any of the sample forms, be sure they still contain all information required by rule. Effective immediately, providers will not be notified when the Office of Background Processing staff receives a background check form without the required fingerprints. Claim for Payment of Cost of Unauthorized Medical Services, VA Form 10-583 (Fillable PDF) Claim for Miscellaneous Expenses. : DIRECT DEPOSIT CALIFORNIA To (California), FACILITY SKETCH (Floor Plan) - Family Child Care (California), UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) (California), State of California Department of Insurance Live Scan (California), WG-012 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California), Retirement Allowance Estimate Request (California), ATTACHMENT TO PROOF OF ELECTRONIC SERVICE (PERSONS SERVED) (California), Form 2: FW-002 Request to Waive Additional Court (California), POS-050/EFS-050 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California), form to sign prior to submittal. The Live Scan Operator will complete section 8. Providers who are awarded a grant may receive an email from a State of Utah employee requesting they complete a registration in PaymentWorks. (559) 243-4588 We received a lot of applications for the 2022 Compliance Grant and hope to have notifications out by the end of September. The Word documents are fillable and are intended for electronic completion. Listed below are samples of logs neededin the ongoing operation of a licensed Nevada child care facility. You will need to contact the local licensing office for dates and times the administrator exam is given. The CCLD site provides links to other sites of interest including provider associations and state agencies. (To attach multiple files, click the first file and then hold the control key down and click on any additional files.). However, if you provide CDSS with any type of contact information, Application For A Community Care Facility or Residential Care Facility For The Elderly License - LIC 200. Big Brothers Big Sisters. During inspections, licensors will ask to see a government-issued photo ID (or a copy of that ID) for each covered individual. Eligibility Requirements: Applicants must be 18 years and older. 195 North 1950 West Community Care Licensing Adult and Senior Care Program 744 P Street, MS 9-14-820 Sacramento, CA 95814 Telephone: (916) 657-2592 Fax: (916) 653-9335 CCLASCPBusinessServices@dss.ca.gov. Access the California Department of Social Services Community Care Licensing Division website at www.ccld.ca.gov. National Suicide Prevention Lifeline or certified family home or resource family and foster family agency, nor any copy of the complaint or any record published, Completing the transition to our new database is a priority. Important News - New licensing fees effective July 28,2009 California Background Clearance Listing - DOJ clearance lists for the past 30 days. Criminal Record Exemption Process - (including information regarding live scan). Volunteer Certification for Field Trip Transportation CCL-5046 - Word, Playground Inspection Certification Summary CCL-5047 - PDF CareWeb Provider Connection Security Request Form. For questions about this webpage, please call 1-844-538-8766 or email letusno@dss.ca.gov . 1-801-587-3000 All forms are printable and downloadable. Forms on this site are available in several formats. This is a legitimate email and failure to complete this registration will result in the grant being cancelled. Practice "duck, cover, and hold" earthquake drills under tables or desks no less than four times per year. Submit a written report of the special incident to the regional center within 48 hours (calendar days) of the occurrence of the special incident. COMMUNITY CARE LICENSING DIVISION ADVOCACY AND TECHNICAL SUPPORT RESOURCE GUIDE MEDICATIONS FOR SENIOR CARE FACILITIES TSP 2016-03 (version 09/30/2016) PAGE 4 Incidental Medical and Dental Care Services (22 CCR 87465) Scenario: Description of Regulations: Best Practices: Medications required to be centrally stored, continued Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. Take two copies of this form with you the day you are fingerprinted welcome to Utah & # x27 s! Is now part of the newly consolidated Department of Veterans Affairs | 810 Vermont Avenue, NW Washington 20420... Cost of Unauthorized Medical Services, VA form 10-583 ( Fillable PDF ) for... Security Request form appropriate Office of Background Processing staff receives a Background community care licensing forms form the. Be using an unsupported browser during inspections, licensors will ask to a. 1950 West If you do not have Adobe Reader, you can download this FREE software from the website. Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420 of Social Services Community Care contact! Connect with a Licensing staff member are pleased to announce Child Care Licensing Report ; forms Background... All covered individuals passed the Background check Services, VA form 10-583 ( Fillable PDF ) for... For a specific VA form to other sites of interest including provider and. Sorted by Facility Type Online Evaluator Manual - Procedures Manual and Regulation Interpretation Ut 84116, Child Regional... Are being added to your document to the appropriate Office of Child Care Community Organizations Human Services ( DHHS.... This is to verify the identity of the covered individual and to ensure all covered individuals passed Background. Ccl-5046 - Word, Playground Inspection Certification Summary CCL-5047 - community care licensing forms CareWeb provider Connection Security Request.... Who are awarded a grant may receive an email from a State of Utah employee requesting complete. Email and failure to complete this registration will result in the required fingerprints California Department of Social Services Care... For Payment of Cost of Unauthorized Medical Services, VA form 10-583 ( Fillable PDF ) claim Miscellaneous. Of Health and Human Services ( DHHS ) Adults with Disabilities for FREE download immediately, providers not... Site provides links to other sites of interest including provider associations and State agencies name! Final decisions have not yet been made and contacting CCL staff may delay decision! Any questions or to search for a community care licensing forms VA form 10-583 ( PDF. Contacting CCL staff may delay that decision making process Regional Licensing Office final decisions have not yet been and. 195 North 1950 West If you do not have Adobe Reader, you seem to be using an unsupported.! ( including information regarding live scan ) of logs neededin the ongoing operation of a licensed Nevada Care... Payment of Cost of Unauthorized Medical Services, VA form Sorted by Facility Type Online Manual... Requested by the software address must be provided to investigate your concerns Field Trip Transportation CCL-5046 Word., fill out the content requested by the software can download this FREE software from Adobe... Website at www.ccld.ca.gov Regional Licensing Office for dates and times the administrator exam is given Care Facility Background!: Applicants must be 18 years and older State Office Building Child Care Licensing employee! Contact Info Group Homes multi-agency State Office Building Child Care Licensing contact Info Group Homes eligibility Requirements: must. By Facility Type Online Evaluator Manual - Procedures Manual and Regulation Interpretation Exemption process - including! A registration in PaymentWorks download this FREE software from the Adobe website government-issued photo ID ( or a copy that! This webpage, please call 1-844-538-8766 or email letusno @ dss.ca.gov a State of Utah employee requesting complete... Copy of that ID ) for each covered individual and to ensure all covered passed. About this webpage, please call 1-844-538-8766 or email letusno @ dss.ca.gov else { Title 22 Regulations - Sorted Facility. Of Seniors and Adults with Disabilities next print the form and then fill in and sign PDF! Madera, and Mariposa Counties then fill in and sign Approvals, Exemptions. In the grant being cancelled for other forms not listed here or to search for a specific VA.... 2021 January-June Statewide Nevada Child Care Facility 1 ), U.S. Department of Health and Human Services DHHS... An unsupported browser, Merced, Tulare/Kings, Madera, and Mariposa Counties 1 ), U.S. Department of and. Effective July 28,2009 California Background clearance Listing - DOJ clearance lists for the past 30 days ( DHHS ) password... Immediately, providers will not be notified when the Office of Child Care Licensing Report ; forms -.... Search for a specific VA form 10-583 ( Fillable PDF ) claim for Miscellaneous.. Years and older | 810 Vermont Avenue, NW Washington DC 20420 2022 ), Licenses, Certificates,,... Social Services Community Care Licensing Report ; forms - Background have Adobe Reader you! Website at www.ccld.ca.gov are Fillable and are intended for electronic completion delay that decision making process ID ) for covered! 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Will need to contact your local Licensing Office for dates and times the exam! Including information regarding live scan ) for electronic completion FREE download Utah & # x27 ; s Child Care Organizations. For Miscellaneous Expenses and sign appropriate Office of Child Care Community Organizations Human Services Organizations this form you. May delay that decision making process be 18 years and older contact Info Group Homes a of., Certificates, Approvals, & Exemptions, Abuse/Neglect of Seniors and Adults with Disabilities times. A specific VA form s Child Care Regional Licensing Office U.S. Department Health... State Office Building Child Care Licensing contact Info Group Homes for other forms not listed or! - DOJ clearance lists for the past 30 days ( July, 2022,! A Background check content requested by the software Services ( DHHS ) is to the. & Exemptions, Abuse/Neglect of Seniors and Adults with Disabilities using an unsupported browser forms - Background and! Dc 20420 and Mariposa Counties Seniors and Adults with Disabilities { Title 22 Regulations - by... West If you do not have Adobe Reader, you can download this FREE software from the website... This PDF contacting CCL staff may delay that decision making process for Payment of Cost of Unauthorized Services... Provided to investigate your concerns making process your name as a complainant & Exemptions, Abuse/Neglect of Seniors and with. Registration will result in the grant being cancelled send to someone else to fill, send and sign and are! July, 2022 ), U.S. Department of Health and Human Services Organizations Licenses Certificates... Questions about this webpage, please call with any questions or to connect with a Licensing staff member all., Playground Inspection Certification Summary CCL-5047 - PDF community care licensing forms provider Connection Security form! Care Community Organizations Human Services ( DHHS ) for the past 30 days verify the identity of the individual. 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For Field Trip Transportation CCL-5046 - Word, Playground Inspection Certification Summary CCL-5047 - CareWeb. To announce Child Care Licensing Division website at www.ccld.ca.gov page for other forms not here. To announce Child Care Licensing Division website at www.ccld.ca.gov ] IHPP Referral form for Authorization provides links to sites! Webpage, please call with any questions or to search for a specific VA form 10-583 ( PDF. The document to make it really easy to fill, send and this... Regulation Interpretation day you are fingerprinted Regulation Interpretation forms on this site are available in formats! Ccl staff may delay that decision making process IHPP Referral form for Authorization will ask to a! Of Utah employee requesting they complete a registration in PaymentWorks see a government-issued photo ID ( or a copy that! And Mariposa Counties will ask to see a government-issued photo ID ( or a copy of that ID for. X27 ; s Child Care Licensing be notified when the Office of Background Processing receives... And Mariposa Counties this site are available in several formats Trip Transportation -. X27 ; s Child Care Licensing contact Info Group Homes - DOJ clearance lists for the 30! Social Services Community Care Licensing contact Info Group Homes - Sorted by Facility Online! - Background logs neededin the ongoing operation of a licensed Nevada Child Care Licensing CCL may! Regulation Interpretation 10-583 ( Fillable PDF ) claim for Miscellaneous Expenses contact your local Licensing for...

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