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California Licensing 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

 

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 - LIC 613C

 

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

 

Preplacement 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

 

 

Refund Policy

CDSS Vendor:

ARF #2000079-735-2

RCFE #2000079-740-2

GH#2000079-730-2

BRN #CEP16081

NHA #CEP1619

40HR# 2000079

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