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California License Forms

| 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 | A Administrative Organization - LIC 309 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 Applicant Information - LIC 215 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 B Balance Sheet - LIC 403 Balance Sheet Supplemental Schedule - LIC 403A Board Of Directors Statement - LIC 165 Budget Information - LIC 420 C CCL/Personnel Record - LIC 501 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 Child's Preadmission Health History - Parent's Report - LIC 702 Civil Penalty Assessment - LIC 421 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 Complaint Report - LIC 802 Complaint Poster - PUB 475 Confidential Names - LIC 811 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 - Children's Residential Facilities - LIC 627B Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities - LIC 627C Consent To A Medical Examination - LIC 627A Contact Sheet - LIC 185 Criminal Background Clearance Transfer Request - LIC 9182 Criminal Record Statement - LIC 508 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 D Death Report - LIC 624A Designation Of Facility Responsibility - LIC 308 E 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 Children's 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 Evidence Of Program Consultant - LIC 313 F Facilities Staff Work Schedule - LIC 507 Facility Evaluation Report - LIC 809 Financial Information Release And Verification - LIC 404 Forms/Records To Keep In Your Family Child Care Home - LIC 311D Foster Family Home Application - LIC 283 Foster Family Home Application Instructions - LIC 283A G Gastrostomy - Tube Care: Physician's Checklist (Child Care Facilities) - LIC 701A Gastrostomy - Tube Care Consent/Verification (Child Care Facilities) - LIC 701B Group Planned Activities - LIC 623 H Health Screening Report - Facility Personnel - LIC 503 I Identification And Emergency Information - LIC 601 Identification And Emergency Information Child Care Centers/Family Child Care Homes - LIC 700 J N/A K N/A L License Application And Instructions For Child Care Centers - LIC 281A License Application And Instructions For Family Child Care Homes - LIC 279A M Monthly Operating Statement - LIC 401 N Notice Of Civil Penalties Due - LIC 422 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 O 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 P Penalty Review - LIC 178 Personal Rights - Child Care Centers - LIC 613A Personal Rights - Children's 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 Personnel Report - LIC 500 Physician's Report - Child Care Centers - LIC 701 Physician's Report For Community Care Facilities - LIC 602 Physician's Report For Residential Care Facilities For The Elderly (RCFE) - LIC 602A Pre-placement Appraisal Information - LIC 603 Q N/A R Record Of Clients Cash Resources For Change Of Licensee - LIC 424 Record Of Client's/Resident's 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 - LIC 301 Reference Request - Adoption Facilitator - LIC 301A Reference Request - Long-Term Care Ombudsman Program - LIC 301B Reference Request - Exemption - LIC 301E Release Of Client/Resident Medical Information - LIC 605A Release Of Information - LIC 122 Removal Confirmation - Exemption Needed - LIC 300A Removal Confirmation - Denial - LIC 300B Removal Confirmation - County - LIC 300E Removal Confirmation – Non-Exemptible - LIC 300D Removal Confirmation – Rescinded - LIC 300C Reporting Requirements By Licensees To The State Department Of Social Services - LIC 306 Request For Live Scan Service - LIC 9163 Resident Appraisal - LIC 603A S Sanitation Inspection Request - LIC 102 Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders - SOC 341a Supplemental Financial Information - LIC 401A Surety Bond - LIC 402 T N/A U Unusual Incident/Injury Report - LIC 624 Unusual Incident/Injury Report - Family Child Care Home - LIC 624B V N/A W N/A X N/A Y Your Right To Make Decisions About Medical Treatment - PUB 325 Z N/A  Resource:CDSSForms - Alphabetic List