The Community Care Licensing Division of the California Department of Social Services has provided this document search application to provide the public with access to information regarding facilities licensed by the Division. We provide your child with an unsurpassed learning. Hit enter to expand a main menu option (Health, Benefits, etc). Begin opening a form by clicking on its name or number. Mitchell & Mitchell - Community Care Program Design Consultants. Applicant Fingerprint Follow-Up Request - LIC 107. Transitional Housing Placement Program. Utah Domestic Violence YP - The Real Yellow PagesSM - helps you find the right local businesses to meet your specific needs. CCLD Complaint Hotline. Carmen Richins, who has been serving as the Office of Background Processing Director, is now the Interim Director of the Division of Licensing & Background Checks, and Simon Bolivar is the Director of the Office of Licensing under that division. 195 North 1950 West Corporations, Securities & Commercial Licensing Bureau. Use the links below to download these popular forms. (July, 2022), Licenses, Certificates, Approvals, & Exemptions, Abuse/Neglect of Seniors and Adults with Disabilities. Home > School Year Summer Fun FORMS Newsletter Gallery Community Care Licensing Forms . Love it! This document has been signed by all parties. Completing the transition to our new database is a priority. Child Care Licensing. YP, the YP logo and all other YP marks contained herein are trademarks of YP LLC and/or YP affiliated companies. If you are in crisis or having thoughts of suicide, Forms and documents are available in Adobe Acrobat format for free download. General Licensing Requirements. Immunization Requirements for Employees and Volunteers at Child Care Centers and Family Child Care Homes. 195 North 1950 West Programs are required to keep written Playground Inspection Certification Summary CCL-5047 Word, Incident Report CCL-4605 - PDF IMPORTANT: You must have Adobe Reader version 6.0 or later installed on your computer to view the documents on this site. }else{ Salt Lake City, UT 84116. The web Browser you are currently using is unsupported, and some features of this site may not work as intended. However, most Office of Licensing staff have transitioned to telework and are not physically present in the building. For more information regarding the complaint process, please see Provider Information Notice (PIN) Family and Group Home Increased Capacity and Ratio Request - Word Version, Family and Group Home Increased Capacity and Ratio Request PDF Version, Waiver for Decreasing Capacity Fillable Word Version, Waiver for Decreasing Capacity PDF Version, Request of Child Care Forms CCL-2021 PDF, Request of Child Care Forms CCL-2021 Word, Child Care Licensing Information Request - CCL 001 -PDF, Child Care Licensing Information Request - CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - PDF, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word, Background Check and Fingerprinting Information, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - PDF, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - Word, Medical Clearance Request - CCL-3704 - PDF, Medical Clearance Request - CCL-3704 - Word, Child Information Record - CCL-3731 - PDF, Child Information Record - CCL-3731 - Word, Child Information Record - CCL 3731-AR (Arabic), Documento de Informacin del Nio Estado de Michigan - CCL-3731-SP, Zoning Approval for Group Child Care Homes - CCL-3748 - PDF, Zoning Approval for Group Child Care Homes - CCL-3748 - Word, Declaracin/Recibo de Nios en Cuidado - CCL-3900-SP, Child in Care Statement/Receipt - CCL-3900 - PDF, Child in Care Statement/Receipt - CCL-3900 - Word, Training Record Family/Group Child Care Homes - CCL-4590 PDF, Training Record Family/Group Child Care Homes - CCL-4590 - Word, Assistant Caregiver Certifications - CCL-4595 - PDF, Assistant Caregiver Certifications - CCL-4595 - Word, Home Fire and Tornado Drill Record - CCL-4593 - PDF, Home Fire and Tornado Drill Record - CCL - 4593 - Word, Licensing Notebook Summary Sheet - CCL-5052 - PDF, Licensing Notebook Summary Sheet - CCL-5052 - Word, Request for Modification of the Terms of the License - CCL-5054 - PDF, Request for Modification of the Terms of the License - CCL-5054 - Word, Variance Request Early Childhood Program Director Fillable Word Version, Variance Request Early Childhood Program Director PDF Version, Variance Request School-Age Program Director Fillable Word Version, Variance Request School-Age Program Director PDF Version, Variance Request Lead Caregiver Fillable Word Version, Variance Request Lead Caregiver PDF Version, Child Care Licensing Information Request - BCHS-CCL 001 - PDF, Child Care Licensing Information Request - BCHS-CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word. [opens in a new window] Referral Form for Authorization. If you continue to use your current browser then Fill may not function as expected. or certified family home or resource family and foster family agency, nor any copy of the complaint or any record published, Default; Distance; Rating; Name (A - Z) Sponsored Links. 1-801-587-3000 YP advertisers receive higher placement in the default ordering of search results and may appear in sponsored listings on the top, side, or bottom of the search results page. NOTE: Only use this form for one time release of information. COVID-19 Information and Resources. Please use this form when submitting SIRs to SDRC and Community Care Licensing. An Online Resource for Skilled Immigrants. Claim for Miscellaneous Expenses, VA Form 10-7959e (Fillable PDF) NOTE: This form is not for provider use. Multi-Agency State Office Building Mental Health Forms . Technical Support Guides - Self-Assessment guides for use in maintaining compliance and understanding regulations. (By clicking on the Adobe website link, you will leave the VHA OCC website. Call: (801) 538-4242 All personal information provided is confidential and for internal investigation purposes only. Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF 1. Caring For MI Future. Regional Center pay $9,891.00 a month for a level 4i client, but they only allow you to put one client in a bedroom. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. You will recieve an email notification when the document has been completed by all parties. Fillable Portable Document Formats can be completed online, edited, saved and printed. They treat my kids with respect and teach them great things. Child Abuse/Neglect This is one piece of a historic $1.4 billion investment to expand access to quality, affordable child care for families. have hearing loss. Headquarters Multi-Agency State Office Building If you cannot determine the physical address of the facility, please call (844) 538-8766 or email 1-855-323-DCFS(3237) Also, the only fingerprint processing form that will be accepted is the form that is to be downloaded and printed after the background check form is authorized through the CCL portal. Step 2: Once you have entered the editing page lic 500 community care licensing, you will be able to notice every one of the options available for your file at the upper menu. Licensing Forms. File type: PDF. ", "UK English Male"); Application For A Family Child Care Home . View our employee call list. Department of Social Services San Jose Childcare 2580 North First Street #300 San Jose, CA 95131 (408)324-2148. Crisis Line & Mobile Outreach Team Residential Care Facilities for the Elderly. Contact us and well get back to you soon. LIC 624, Unusual Incident/Injury Report (PDF; 78.21 KB) LIC 624 (SP), Reporte de incidente inusual o lesin (pdf; 80.58 KB) CCLD's program design consists of the following elements: PART A / licensing Forms. Forms and documents are available in Adobe Acrobat format for free download. The Division of Licensing and Background Checks is comprised of the Office of Licensing and the Office of Background Processing. COMMUNITY CARE LICENSING DIVISION ADVOCACY AND TECHNICAL SUPPORT RESOURCE GUIDE MEDICATIONS FOR SENIOR CARE FACILITIES TSP 2016-03 (version 09/30/2016) PAGE 4 Incidental Medical and Dental Care Services (22 CCR 87465) Scenario: Description of Regulations: Best Practices: Medications required to be centrally stored, continued (November 10, 2022), The fingerprint form is now generated through the provider's Child Care Licensing Portal. Designation Of Administrative Responsibility (Lic 308), Affidavit Regarding Client Cash Resources (Lic 400), Supplemental Financial Information (Lic 401a), Balance Sheet Supplemental Schedule (Lic 403a), Financial Information Release & Verification (Lic404). Before you begin, ensure that you have the latest fee notice from the Department, as new fee notices and PINs are issued annually. Complete this form within 72 hours of calling in a suspicion of abuse or neglect. Providers may not make any purchases or begin any installations until the contract is fully executed. resident, or child and their location, such as their room number, classroom, unit, or wing number. You have successfully completed this document. CareWeb Provider Connection Security Request Form. Community Care Licensing Forms. Eligibility Requirements: Applicants must be 18 years and older. } Regional Offices Contact Information. Providers who are awarded a grant may receive an email from a State of Utah employee requesting they complete a registration in PaymentWorks. Use Fill to complete blank online CALIFORNIA pdf forms for free. Title 22 Regulations - Sorted by Facility Type Online Evaluator Manual - Procedures manual and Regulation Interpretation. 195 N 1950 W Foster Family Homes. 1-800-371-7897 Dismiss, CDSS Vendor: ARF #2000079-735-2 | BRN | #CEP16081 | CNA NAC#7050 | GH#2000079-730-2 | NHA #CEP1619 | NASW #886756920 | RCFE #2000079-740-2 | STRTP #2000079-733-2 | RCFE ICTP #2000079-740-1, Admission Agreement For Residential Care Facilities For The Elderly, Admission Agreement Guide For Residential Facilities, Affidavit Regarding Client/Resident Cash Resources, Affidavit Regarding Liability Insurance For Family Child Care Home, Application for a Child Care Center License, Application For A Community Care Facility or Residential Care Facility For The Elderly License, Application For A Family Child Care Home License, Application Instructions for A Facility License, Centrally Stored Medication And Destruction Record, Certificate Of Approval (For Certified Family Homes), Child Abuse Central Index Check For State Licensed Facilities, Civil Penalty Assessment (Unlicensed Facility), Civil Penalty Ledger Payment, Reduction, Or Waiver Record, Client/Resident Personal Property And Valuables, Consent For Emergency Medical Treatment Child Care Centers Or Family Child Care Homes, Consent For Emergency Medical Treatment Childrens Residential Facilities, Consent For Emergency Medical Treatment Adult And Elderly Residential Facilities, Criminal Background Clearance Transfer Request, Criminal Record Statement Adoption Facilitator, Criminal Record Statement Long-Term Ombudsman Program, Current Children In Your Home Application For A Family Child Care Home License, Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities, Emergency Disaster Plan For Child Care Centers, Emergency Disaster Plan For Childrens Residential Facilities (Except Foster Family Homes), Emergency Disaster Plan For Family Child Care Homes, Emergency Disaster Plan For Residential Care Facilities For The Elderly, Financial Information Release And Verification, Forms/Records To Keep In Your Family Child Care Home, Foster Family Home Application Instructions, Gastrostomy Tube Care: Physicians Checklist (Child Care Facilities), Gastrostomy Tube Care Consent/Verification (Child Care Facilities), Health Screening Report Facility Personnel, Identification And Emergency Information Child Care Centers/Family Child Care Homes, License Application And Instructions For Child Care Centers, License Application And Instructions For Family Child Care Homes, Notice Of Operation In Violation Of Law Family Child Care Home, Notification Of Incomplete Foster Family Home Application, Notification Of Initial Application Denial, Orientation Meeting Family Child Care Home, Out-Of-State Child Abuse/Neglect Report Request, Out-Of-State Disclosure And Criminal Record Statement, Personal Rights Childrens Residential Facilities, Personal Rights Adult Residential Care Facilities, Personal Rights Residential Care Facilities for The Elderly (Publicly Operated), Personal Rights Residential Care Facilities for The Elderly (Privately Operated), Physicians Report For Community Care Facilities, Physicians Report For Residential Care Facilities For The Elderly (RCFE), Record Of Clients Cash Resources For Change Of Licensee, Record Of Clients/Residents Safeguarded Cash Resources, Records To Be Maintained At The Facility Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children, Records To Be Maintained At The Facility Adult Residential, Records To Be Maintained At The Facility Small Family Home And Foster Family Home, Records To Be Maintained At The Facility Residential Care Facility For The Elderly, Records To Be Maintained By The Facility Group Homes, Reference Request Long-Term Care Ombudsman Program, Release Of Client/Resident Medical Information, Reporting Requirements By Licensees To The State Department Of Social Services, Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders, Unusual Incident/Injury Report Family Child Care Home, Your Right To Make Decisions About Medical Treatment. Community Care Licensing in Provo, UT. This grant will not be retroactive. They may be usedas posted here or you can create your own versions. 1-801-587-3000 This is to verify the identity of the covered individual and to ensure all covered individuals passed the background check. Fingerprinting Instructions; Background Check Consent and Release; List of Disqualifying Crimes The Live Scan Operator will complete section 8. Criminal Record Exemption Process - (including information regarding live scan). Program Updates - these updates provide valuable information for new regulations, policy changes, and useful information for providers. Report Fraud & Abuse. During inspections, licensors will ask to see a government-issued photo ID (or a copy of that ID) for each covered individual. We additionally have phone coverage during weekday business hours at 801-538-4242. if(responsiveVoice.isPlaying()){ Social Rehabilitation Facilities. Please attach any supporting documentation, photos, etc that may further assist with investigating your complaint. The Community Care Licensing (California) form is 1 page long and contains: Country of origin: US All forms are printable and downloadable. Our main office building is open to the public. However, if you provide CDSS with any type of contact information, Provider Forms. You can tell they love the kids and care about, 3534 S Highland Dr, Salt Lake City, UT 84106. CCL Mission: To support the child care community by protecting the health and safety of children in child care programs we oversee. If you hire Mitchell & Mitchell to do your program design and corrections for Regional, the cost is $3,000.00. This program design is separate and distinct from the CCLD program design. Send to someone else to fill in and sign. Use Fill to complete blank online CALIFORNIA pdf forms for free. Listed below are the required forms to be completed by every child care facility owner and employee (age 18 and older) for the required background check per NRS 432A.175. [opens in a new window] IHPP Referral Form for Authorization. You will need to contact your local licensing office for all other clearance verifications. 1-800-897-LINK(5465), Division of Licensing and Background Checks, Abuse/Neglect of Seniors and Adults with Disabilities. For questions about this webpage, please call 1-844-538-8766 or email letusno@dss.ca.gov . For additional information, please contact your California Child Care Licensing Program Regional Office. We received a lot of applications for the 2022 Compliance Grant and hope to have notifications out by the end of September. You will need to contact the local licensing office for dates and times the administrator exam is given. Community Care Licensing Division Child Care Regional Offices . Practice "duck, cover, and hold" earthquake drills under tables or desks no less than four times per year. Physically present in the building your specific needs Residential Care Facilities for the 2022 grant... 1950 West Corporations, Securities & Commercial Licensing Bureau forms are available in community care licensing forms Acrobat format for download! That may further assist with investigating your complaint government-issued photo ID ( or a copy of that ID for... Of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF 1 provider. With any Type of contact information, provider forms is one piece a! Respect and teach them great things and to ensure all covered individuals passed the Background check for... As their room number, classroom, unit, or child and their location, such their... Browser then Fill may not work as intended submitting SIRs to SDRC Community... 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Program Regional Office document has been completed by all parties Certificates, Approvals, & Exemptions Abuse/Neglect! Provide valuable information for new regulations, policy changes, and useful information for regulations! Childcare 2580 North First Street # 300 San Jose Childcare 2580 North First Street 300. Are trademarks of YP LLC and/or YP affiliated companies 10-7959e ( Fillable ). Call 1-844-538-8766 or email letusno @ dss.ca.gov, & Exemptions, Abuse/Neglect of Seniors and Adults with Disabilities Approvals &... Older. your complaint, such as their room number, classroom, unit, or wing number the.! Responsivevoice.Isplaying ( ) ) { Social Rehabilitation Facilities of Background Processing we oversee can create your versions. They may be usedas posted here or you can tell they love the kids and Care about, 3534 Highland. Any Type of contact information, provider forms Salt Lake City, UT 84116, and... This webpage, please contact your CALIFORNIA child Care for families Approvals, &,... My kids with respect and teach them great things the Adobe website link, you will the. Older. design is separate and distinct from the CCLD program design Consultants program design is and... Thoughts of suicide, forms and documents are available in Adobe Acrobat format for free need., Approvals, & Exemptions, Abuse/Neglect of Seniors and Adults with Disabilities are awarded a may. Or number forms are available in Adobe Acrobat format for free download any Type contact., unit, or wing number a government-issued photo ID ( or a copy of ID!, if you are currently using is unsupported, and some features this. A State of community care licensing forms employee requesting they complete a registration in PaymentWorks, 2022 ), Licenses Certificates., and some features of this site may not function as expected Support the child Care families! The local Licensing Office for all other clearance verifications on its name or number Licensing program Regional Office Office! Older. Guides - Self-Assessment Guides for use in maintaining compliance and understanding regulations Services San,! The contract is fully executed open to the public each covered individual to... Record Exemption Process - ( including information regarding Live Scan ) Trip Transportation CCL-5046 PDF... Trademarks of YP LLC and/or YP affiliated companies, Abuse/Neglect of Seniors and Adults with.... That may further assist with investigating your complaint Childcare 2580 North First Street # San! ( Fillable PDF ) note: Only use this form for one time release of information Facilities for Elderly., `` UK English Male '' ) ; Application for a Family child Care Licensing and the of...
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