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
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
E
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
H
I
J
N/A
K
N/A
L
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
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
- 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
Z
N/A
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