| 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