California License Forms

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

Balance Sheet - LIC 403

Balance Sheet Supplemental Schedule

- LIC 403A

Board Of Directors Statement - LIC 165

Budget Information - LIC 420

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

Death Report - LIC 624A

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 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

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

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

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

N/A

N/A

License Application And Instructions For Child Care Centers - LIC 281A

License Application And Instructions For Family Child Care Homes - LIC 279A

Monthly Operating Statement - LIC 401

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

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

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

N/A

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

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

N/A

Unusual Incident/Injury Report - LIC 624

Unusual Incident/Injury Report - Family Child Care Home - LIC 624B

N/A

N/A

N/A

Your Right To Make Decisions About Medical Treatment - PUB 325

 N/A