cdss forms spanish

Those speculating on CDSs are paying about 70 cents to get $1 back if the Treasury misses a bond payment and the CDS payout triggers. CPS Awareness Poster - Spanish (PDF) The CPS Awareness Poster is available electronically in 11 other languages. When completed per MPP Section 21-115.2, including Armenian, Chinese and Spanish forms, the translations will be posted on our website. CCFRM604 (11/13) EN LG 4 Step 1: Tell us about the adult who will be our main contact for this application (continued) Are you applying for a child less than 1 year old? State of California - Health and Human Services Agency California Department of Social Services LIC 700 (10/19) (CONFIDENTIAL) Page 2 of 2 NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY Notice of Action CD-7617 (DOC) Available Translations of the Notice of Action. 2. About. Cuando se ampla, se proporciona una lista de opciones de bsqueda para que los resultados . For more consumer information on security please see the California Department of Justices, Security Awareness 1 Cdss Salaries in Berlin, Germany provided anonymously by employees. Traduzioni in contesto per "CDSS a" in italiano-inglese da Reverso Context: In passato, gli studenti dovevano frequentare la scuola Ezondweni CDSS a 6 km di distanza. Calendar Fiscal Year 2019-20 EESD-9730 (XLS) For personal information access requests, send an email to CDSS Public Inquiry and Response Unit piar@dss.ca.gov and/or call (916) 651-8848. Translated Spanish Forms Beginning With Letters A Through L Problems with downloading forms? If your office has internet access you may obtain this notice from the CDSS webpage at: Forms/Brochures. FCCH - Pre-Orientation Registration Information: Wait! CHDP Provider Resources. Pasar al contenido principal LinkedIn. March XX, 2010ALL-COUNTY LETTER (ACL) NO. NA 995 (5/13) - Food Stamp Notice of Denial/Disqualification For The California Food Assistance Program. Copies of the translated notices can be . Child Care Services Forms Annual Summary of Eleven- and Twelve-Year-Old Children in Early Learning and Care Division (ELCD) Child Care Programs CD-9608Bx (XLS) Attendance and Fiscal Reporting forms are available through the Child Development Fiscal Services website. A list of organizations which have child care services as their primary area of interest. CF 285 (4/15) RIGHTS AND RESPONSIBILITIES You have a responsibility to: Give the County all information needed to determine your eligibility. Statewide Information Management Manual (SIMM) 5310 - A & B. There are three variants; a typed, drawn or uploaded signature. Box) City State Zip EBT card was reported lost/stolen to the county or . When a sentence contains consecutive adverbs, we only add the ending -mente to the last adverb. Jul 2021 - Present1 year 8 months. Combining years of human cybersecurity expertise and insights with ML-powered and Cloud-delivered products and services . Expandir todo. : 20-22 Page 4 October 28, 2020 GEN 1365 Language Access Services for Limited-English Proficient and Non- #OpenAI Microsoft ChatGPT Healthcare #digitalhealth #saude5ponto0 Form CD-7617, (Rev 6/14) 1. Privacy Notice on Collection Blackford Middleton is a physician & health informatics innovator committed to transformation.curing what ails healthcare. contact the Forms Management Unit at . Fernando Uzuelli Ampliar bsqueda. Join or sign in to find your next job. Here's How - Use Starting June 1, 2020, CW 2166 (11/21) - Multilingual Work Really Pays! You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com. 6.CHDP Forms. The information collected will not be shared with any other government agencies, unless required or allowed by law to administer programs. Your Name. Here's How, CW 2184 (8/16) - CalWORKS 48-month Time Limit, CW 2184 (4/21) - CalWORKs 60-Month Time Limit, CW 2186A (12/12) - CalWORKs Exemption Request Form, CW 2186A (4/21) - CalWORKs Exemption Request Form, CW 2186B (4/21) - CalWORKs Exemption Determination, CW 2187 (4/11) - Your CalWORKs 48-Month Time Limit, CW 2187 (4/21) - Your CalWORKs 60-Month Time Limit, CW 2188 (4/02) - Verification Of Aid For The Temporary Assistance For Needy Families (TANF) Program, CW 2189 (3/15) - Notice of Your CalWORKs Time Limit - 42nd Month On Aid, CW 2189A (9/20) Notice Of Your CalWORKs Time Limit 54TH Month On Aid (Use Starting May 1, 2022), CW 2189B (9/20) Notice Of Your CalWORKs Time Limit 57TH Month On Aid (Use Starting May 1, 2022), CW2190A (4/16) - CalWORKs 48-Month Time Limit Extender Request Form, CW2190B (5/16) - CalWORKs 48-Month Time Limit Extender Determination Denial Form, CW 2190B (4/21) - CalWORKs 60-Month Time Limit Extender Determination Form, CW 2191 (4/21) - Time On Aid Verification For CalWORKs/TANF 60-Month Time Limits, CW 2192 (4/21) - Tracking Non-California TANF Assistance For Time Limits, CW 2200 (5/22) - Request For Verification, CW 2200LP (6/19) - Request For Verification, CW 2201 (6/09) - Unemployment Insurance Benefits Referral Form, CW 2203 (11/09) - Request For Supplemental Payment By Check Or Direct Deposit, CW 2205 (10/12) - New Rules For CalWORKs Welfare-To-Work Activities, CW 2208 (2/13) - Your Welfare-To-Work 24-Month Time Clock, CW 2209 (12/14) - Immunization Good Cause Request Form, CW 2211 (11/14) - Your CalWORKs Reporting Rules Have Changed, CW 2212 (11/14) - The Rules For Your CalWORKs Case Have Change, CW 2213 (10/15) - Response To Request To Inspect Case Record CalWORKs, CalFresh, TCVAP, And Refugee Programs, CW 2215 (10/20) - California Work Opportunity and Responsibility to Kids (CalWORKs) Important Information for Safety Net And Certain Child-Only Case, CW 2217 (1/15) - CalWORKs Request For Voluntary Repayment, CW 2218 (12/20) - Rights, Responsibilities And Other Important Information For The California Work Opportunity And Responsibility To Kids (CalWORKs) Program (Non-Needy Caretaker Relative With Relative Foster Child) - Use Starting June 1, 2021, CW 2218 (3/22) - Rights, Responsibilities And Other Important Information For The California Work Opportunity And Responsibility To Kids (CalWORKs) Program (Non-Needy Caretaker Relative With Relative Foster Child), CW 2219 (5/16) Application For California Work Opportunity And Responsibility To Kids (CalWORKs) (Non-Needy Caretaker Relative With Relative Foster Child), CW 2223 (9/18) - Demographic Questionnaire For CalWORKs, Refugee Cash Assistance (RCA), Entrance Cash Assistance (ECA), Trafficking And Crime Victims Assistance Program (TCVAP) And CalFresh Programs, CW 2224 (2/20) - CalWORKs Home Visiting Initiative (HVI), DFA 377.1A (3/02) - Notice Of Denial Or Pending Status, DFA 377.7A (4/21) - Notice Of Administrative Disqualification, DFA 377.7D2 (10/00) - Food Stamp Repayment Notice for Administrative Errors Only, Final Notice, DFA 377.7E (7/04) - Food Stamp Repayment Agreement For Administrative Errors Only, DFA 377.7F (6/18) - CalFresh Overissuance Notice For An Intentional Program Violation (IPV) Or Status Change From Inadvertent Household Error (IHE) To An IVP, DFA 377.7F LP (6/18) - CalFresh Overissuance Notice - Intentional Program Violation (IPV), DFA 377.7F1 (10/00) - Food Stamp Repayment Notice for an Intentional Program Violation (IPV)Only, Final Notice, DFA 377.7G (5/02) - Food Stamp Repayment Notice for an Intentional Program Violation (IPV) Only, DFA 377.10 (6/04) - Food Stamp Notice Of Discontinuance, DPA 13 (7/99) - Request For State Hearing Before The State Department Of Social Services, DPA 19 (6/22) - Appointment OfAuthorized Representative, DPA 315 (7/99) - Withdrawal/Conditional Withdrawals Of Request For Hearing, DPA 421 (7/99) - Notification Of Open Record And Waiver Of Time, DPA 435 (1/18) - County Allegation Of Intentional Program Violation/Statement Of Position (Request For An Administrative Disqualification hearing), DPA 436B (8/18) - County Information Letter, DPA 479 (12/17) - Administrative Disqualification Hearing Waiver - CalWORKs/Food Stamps, EBT 1232 (6/22) - CalFresh Notice Of Action - EBT Account, EBT 2216 (10/22) - EBT Surcharge Free - Direct Deposit Handout, EBT 2259 (11/21) - Report Of Electronic Theft Of Benefits, EBT 2259A (11/21) - EBT Scamming Acknowledgement, EBT 2260 (8/21) - Excessive Card Replacement Warning Letter, EFA 7 (7/21) - The Emergency Food Assistance Program (TEFAP) Certification Of Eligibility, EFA 7A ENG/SP (3/11) - Emergency Food Assistance Program (EFAP) Certification Of Eligibility, EFA 14 (6/22) - The Emergency Food Assistance Program (TEFAP) 2022Income Guidelines, EFA 15 (6/22) - Alternate Pick-Up Request Form The Emergency Food Assistance Program (TEFAP) 2022 Income Guidelines, FC 2 (11/04) - Statement of Facts Supporting Eligibility For AFDC-Foster Care (FC), FC 2 NM (2/12) - Statement of Facts Supporting Eligibility For AFDC-Extended Foster Care (EFC), FC 31 (8/16) Accreditation Reimbursement Request. Program Summary The Child and Adult Food Care Program (CACFP) is a state and federally funded Child Nutrition Program (CNP) designed to provide nutritious meals and snacks served to infants, children, and adults. Santa Clara, California, United States. CDSS CDs Ca Form. be ready to get more Create this form in 5 minutes or less Get Form Video instructions and help with filling out and completing Personal Rights LIC 613a Form Find a suitable template on the Internet. may include calling radiology providers for copies of mammogram reports) Language Access Complaint Form. It is a trade that is more about possibilities than probabilities, and the people making them probably run a big fund with all sorts of positions, some speculative, in hopes that one or three actually work. Contenido Curso . Press Done after you complete the form. Date: _____ Full Medi-Cal benefits were granted pending verification of immigration status. Application for Registration as a School Audiometrist - PM 101 Instructions for Earnings Verification Form. Specializing in model development, analysis and research in exotic derivatives and XVAs within Fixed Income. The languages include: Arabic, Chinese (simplified and traditional), Farsi, Hmong, Khmer, Korean, Punjabi, Russian, Tagalog, Vietnamese. That's what a next generation of #cdss look like. The California Department of Social Services (CDSS) Privacy Notice on Collection covers our practices regarding personal information collected when completing applications and forms (online or hardcopy) for our various programs. Expertise in implementation and analysis of vanilla and exotic models for derivatives, XVAs, multiple curve construction, numerical methods including Monte-Carlo and Finite . Quality assurance review of submitted forms for PSU; Troubleshooting for missing elements (i.e. NA 1208 (2/00) - Basic Approval. Subscribe. lento, lenta lenta (mente), silencioso silenciosamente. CDs ca form, create your personalized electronic signature in a couple quick steps, and streamline your workflow without leaving your browser. The California Department of Social Services (CDSS) Privacy Notice on Collection covers our practices regarding personal information collected when completing applications and forms (online or hardcopy) for our various programs. Choose My Signature. Forms for contractors of Early Learning and Care Division subsidized child care to give parents when family situations change. SOC 2298 - In-Home Supportive Services (IHSS) Program and Waiver Personal Care Personal Services (WPCS) Live-In Self-Certification Form for Federal and State Wage Exclusion. The California Department of Social Services (CDSS) serves, aids and protects needy and vulnerable children and adults in ways that strengthen and preserve families, encourage personal . 11.Medi-Cal News Flash. Forms &. The prisoner's primary language is Spanish other (specify): b. I certify that I translated Order for Prisoner's Appearance at Hearing Affecting Parental Rights (JV-450) and this form for the prisoner in the prisoner's primary language to the best of my ability. ApplicpatoiCall Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). All Presumptive Eligibility forms for Pregnant Women will now be made available on our provider website for the following form(s): MC 311. Safeguarding Information for the Financial Assistance Programs - 45 CFR section 205.50. The adverbs before take the feminine form of the adjective. PDF fill-and-print forms may be completed online and printed to hardcopy to be signed and mailed in or submitted in person to an eligibility worker for processing. Resources for Parents and Families Resources for Parents and Families Information for parents and family members about early childhood education. The County will give you information about what, when, and how to report. Click the download button to access the Contract Data Summary Sheet for all other contract types (not Fire, Police or Schools). Personal information may include: name, social security number, physical description, home address, home telephone number, education or financial, medical or employment history, etc. 1. Child Abuse Central Index Forms Child Abuse and Neglect Reporting Forms The following forms are for use by government agencies and mandated reporters pertaining to child abuse cases. Questions: Early Education Division | 916-322-6233 Last Reviewed: Wednesday, February 22, 2023 MC 300 Forms: MC 306 (11/15) - Appointment of Representative; Alt: Spanish (01/08) MC 322 (05/07) - Real and Personal Property - Supplement to Medi-Cal Mail-in Application Complaint forms are available here: DHCS-1044-DHCS-DISCRIMINATION-COMPLAINT-FORM.pdf. Energy Assistance Application. Services Approved to Begin: Date. Failure to provide requested information may result in a denial of services. Welfare and Institutions Code section 10850. 5. Recipient of Services. Mailing Address (Number, Street, P.O. Empezar. Este curso est diseado para el personal que regresa del Programa de Alimentos para el Cuidado de Nios y Adultos (CACFP) y revisar los reglamentos y procedimientos del CACFP para ayudar a los operadores del CACFP . **Due to browser constraints please download forms for full functionality. Create your signature and click Ok. Press Done. SW Procedures When Sending Placement Paperwork to Mexico Alignment with SET. Toma este curso. Give it a little time before the Ihss Medical Certification Form is loaded CDSS, Clinical Pathways, Evidence Based Medicine, Healthcare provider space and HIS, contributed for Online training material . They will direct you to your program representative. Multipurpose Senior Services Program. New: CDSS has launched a Mobile App for this website now available on the App Store and Google Play. For more information, review the online CDSS Privacy Policy Statement. Sacramento, CA 95899-7413. No inscrito. Any personal information collected is governed by the requirements of the following authorities and all other laws pertaining to personal information: CDSS collects personal information directly from individuals who volunteer to obtain some of our services. Give the County proof of the information you have when it is needed. Earnings Verification Form. (916) 440-7370, 711 (California State Relay) Email: CivilRights@dhcs.ca.gov. Change in Service. Document Verification Request (INS Form G-845) and copies of documentation of satisfactory immigration status sent to INS. Security Awareness, Copyright 2023 California Department of Social Services. Double check all the fillable fields to ensure complete precision. Example: La araa descendi lenta y silenciosamente. c19-4 (Directing All Laboratories Conducting COVID-19 Diagnostic Tests to Report COVID-19 Test Information - Including Positive, Negative, and Inconclusive Test Results - To Local and State Public Health Authorities) issued on March 24, 2020 is rescinded in full in accordance with Section 9 of that Order. Precio. School or child care personnel then fill in date (month/day/year) of each immunization the student has received from the Immunization Record presented by Start on editing, signing and sharing your Ihss Medical Certification Form online with the help of these easy steps: Click on the Get Form or Get Form Now button on the current page to make access to the PDF editor. Individuals who provide personal information to CDSS have the right to review the information for accuracy and completeness and to request corrections or deletions. Emergency Disaster Drill Log California Community Care Licensing (CCL) Requirements Licensed child care programs must conduct emergency drills at least once every 6 months. Exciting news - CDSS alumnus Patrick Bayer will be taking up a full professor position at the University of Glasgow in May. **Due to browser constraints please download forms for full functionality. (Spanish) Franais (French) . Este botn muestra el tipo de bsqueda seleccionado. Form ELCD 9600, Page 1, (REV. 1.ACEs Aware Toolkit. Your Organization. Access forms used by the Department of Health Care Services. Note: The signed CBA and the completed Contract Data Summary Sheet (CDSS . The completed AD-3027 form or letter must be submitted to USDA . First event comprising of interactive sessions with artists of different art forms, demonstrations and exhibition completed successfully on December 1 2019. . Complete child's name and address information section, or ask parent or guardian to complete this section only. Save prior to filling it out. El propsito de las visitas y las cartas es asegurar que los requisitos del Programa se estn cumpliendo y que los servicios autorizados sean necesarios para que usted permanezca en su hogar de una manera segura. How to complete the Get And Sign California lic 702 2008-2019 Form online: To get started on the form, use the Fill camp; Sign Online button or tick the preview image of the form. LIC 279A (5/17) - License Application And Instructions For Family Child Care Homes. California Department of Social Services The following are forms for the Child Health and Disability Prevention Program. Search By Facility Number Search By Facility Group Foster Family Agencies 24 Hour Residential Care for Children Adult Residential and Daycare Elderly Assisted Living Child Care Home Care Organization All Facility Types [Back] What salary does a Cdss earn in Berlin? If you suspect a case of child abuse in your neighborhood, you should contact your county child welfare agency or local law enforcement agency. The spider descended slowly and silently. 2074-EG. Notice of Action (Complete Either 1.A. Please do not provide personal information that is not requested. Servicios Sociales de California (CDSS), y/o el Condado en donde yo reciba servicios. Notice of Action: Approval (DOC) Available Translations of the Notice of Action: Approval. Ph'D in Physics and quantitative Mathematics background. 08/01/2011. Join to apply for the ASSOCIATE GOVERNMENTAL PROGRAM ANALYST role at California Department of Social ServicesASSOCIATE GOVERNMENTAL PROGRAM ANALYST role at Apply a check mark to indicate the choice where required. Use this step-by-step instruction to fill out the Get And Sign Preadmission health history spanish 2008-2019 Form swiftly and with idEval precision. The California Department of Social Services (CDSS) serves, aids and protects needy and vulnerable children and adults in ways that strengthen and preserve families, encourage personal . The California Department of Aging (CDA) administers programs that serve older adults, adults with disabilities, family caregivers, and residents in long-term care facilities . Effective immediately, Health Officer Order No. Information Practices Act - Civil Code section 1798 et seq. Report changes as required. 2074-Inst. 10/11/2022. Public Records Act - Government Code section 6250 et seq. Tips for Using Adobe PDF Files, Copyright 2023 California Department of Social Services, ICPC 100A Instructions (7/20) Instructions For Completing Form ICPC 100A Interstate Compact On The Placement Of Children Request, ICPC 100A (11/20) Interstate Compact On The Placement Of Children Request, ICPC 100B Instructions (7/20) Instructions For Completing Form ICPC 100B Interstate Compact Report On Childs Placement Status, ICPC 100B (7/20) Interstate Compact On The Placement Of Children Report On Childs Placement Status, IHSS-E 002 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Provider For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances, IHSS-E 003 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances, IHSS-E 004 (4/17) - In-Home Supportive Services Program Notice Of Non-Receipt Of Exemption From Workweek Limits Provider Agreement (APD 006), IHSS-E 005 (1/17) - In-Home Supportive Services Program Notice Of Ineligibility To Request Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) - Provider, IHSS-E 006 (4/17) - In-Home Supportive Services Program Notice To Provider Of Expiration Of Exemption From Workweek Limits, IHSS-E 007 (4/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Providers Expiration Of Exemption From Workweek Limits, KG 1 (12/11) - Kin-GAP Mutual Agreement For 18 Year Olds, KG 2 (1/11) - Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (Kin-GAP) Program, KG 3 (12/11) - Kin-GAP Mutual Agreement For Nonminor Former Dependents, KG 4 (2/14) - Kinship Guardianship Assistance Payment (Kin-GAP) Program - Nonrecurring Legal Guardianship Expenses Agreement, KG 5 (2/14) - Kinship Guardianship Assistance Payments (Kin-GAP) Program Nonrecurring Legal Guardianship Expenses Form, LIC 00 (8/17) - Conversion to Resource Family: Release of Information, LIC 00A (2/17) - Conversion - Resource Family Application, LIC 01A (9/21) - Resource Family Application, LIC 01C (7/16) - Resource Family Application-Confidential, LIC 03 (8/21) - Resource Family Home Health And Safety Assessment Checklist Document For Agency Use Only, LIC 05A (8/21) - Resource Family Approval Certificate, LIC 12 (8/21) - Resource Family Approval Document Alternative Plan (DAP), LIC 102 (9/99) - Sanitation Inspection Request, LIC 107 (9/00) - Applicant Fingerprint Follow-Up Request, LIC 125 (3/21) - Entrance Checklist - Child Care Centers, LIC 126 (3/21) - Entrance Checklist - Family Child Care Homes, LIC 165 (8/07) - Board Of Directors Statement, LIC 178 (12/15) - Deficiency/Penalty Review, LIC 184 (5/00) - Notification Of Incomplete Application, LIC 184A (1/08) - Notification Of Incomplete Foster Family Home Application, LIC 184B (3/22) - Notification Of Incomplete Application - Family Child Care Home, LIC 184C (3/22) - Notification Of Incomplete Application (NOIA) Child Care Centers -Pre-30-Day NOIA, LIC 184D (3/22) - Notification Of Incomplete Application (NOIA) Child Care Centers - 30-Day NOIA, LIC 184E (3/22) - Notice Of Incomplete Application (NOIA) Changes To Corporate Status, LIC 186A (10/04) - Orientation Meeting Family Child Care Home, LIC 192 (7/03) - Notification Of Initial Application Denial, LIC 195 (8/19) - Notice Of Operation In Violation Of Law, LIC 195A (8/19) - Notice Of Operation In Violation Of Law - Family Child Care Home, LIC 198 (1/22) - Child Abuse Central Index Check For County Licensed Facilities, LIC 198B (8/21) - Out-Of-State Child Abuse/Neglect Report Request, LIC 200 (2/11) - Application For A Community Care Facility or Residential Care Facility For The Elderly License, LIC 200TM (6/18) - Temporary Manager Application For Provisional License, LIC 200A (2/17) - Application for a Child Care Center License, LIC 201F (2/01) - Annual License Fee Notice - County, LIC 215TM (11/18) - Temporary Manager Candidate List Application Information, LIC 216TM (11/18) - Temporary Manager Appointment Applicant Information, LIC 229 (9/99) - Certificate Of Approval (For Certified Family Homes), LIC 279 (2/23) - Application For A Family Child Care Home License, LIC 279A (5/17) - License Application And Instructions For Family Child Care Homes, LIC 279B (1/22) - Current Children In Your Home - Application For A Family Child Care Home License, LIC 281 (9/04) - Application Instructions for A Facility License, LIC 281A (1/07) - License Application And Instructions For Child Care Centers, LIC 281D (1/17) - Application And Supporting Documentation Checklist Foster Family Agency, LIC 281E (1/17) Application And Supporting documentation Checklist Short - Term Residential Therapeutic Program, LIC 282 (1/22) - Affidavit Regarding Liability Insurance For Family Child Care Home, LIC 283 (4/10) - Foster Family Home Application, LIC 283A (12/07) - Foster Family Home Application Instructions, LIC 300A (01/22) - Removal Confirmation - Exemption Needed, LIC 300B (9/03) - Removal Confirmation - Denial, LIC 300C (9/03) Removal Confirmation Rescinded, LIC 300D (9/03) - Removal Confirmation Non-Exemptible, LIC 300E (12/03) - Removal Confirmation - County, LIC 301A (8/07) - Reference Request - Adoption Facilitator, LIC 301B (8/07) - Reference Request - Long-Term Care Ombudsman Program, LIC 301E (10/22) - Reference Request - Exemption, LIC 306 (3/01) - Reporting Requirements By Licensees To The State Department Of Social Services, LIC 308 (11/02) - Designation Of Facility Responsibility, LIC 309 (6/01) (PUBLIC) - Administrative Organization, LIC 311A (2/22) - Records To Be Maintained At The Facility - Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children, LIC 311B (4/05) - Records To Be Maintained By The Facility - Group Homes, LIC 311C (4/05) - Records To Be Maintained At The Facility - Adult Residential, LIC 311D (2/22) - Forms/Records To Keep In Your Family Child Care Home, LIC 311E (4/05) - Records To Be Maintained At The Facility - Small Family Home And Foster Family Home, LIC 311F (4/05) - Records To Be Maintained At The Facility - Residential Care Facility For The Elderly, LIC 313 (12/01) - Evidence Of Program Consultant, LIC 400 (1/99) - Affidavit Regarding Client/Resident Cash Resources, LIC 401 (3/01) - Monthly Operating Statement, LIC 401A (3/99) - Supplemental Financial Information, LIC 403A (9/11) - Balance Sheet Supplemental Schedule, LIC 404 (7/99) - Financial Information Release And Verification, LIC 405 (8/01) - Record Of Client's/Resident's Safeguarded Cash Resources, LIC 406 (5/13) - Client/Resident Cash Sheet, LIC 421A (6/22) - Civil Penalty Assessment (Unlicensed Facility), LIC 421BG (5/19) - Civil Penalty Assessment Caregiver Background Check, LIC 421CC (6/22) - Civil Penalty Assessment Child Care, LIC 421D (ASC) (6/17) - Civil Penalty Assessment Death/Serious Bodily Injury/Physical Abuse (ASC), LIC 421D (CC) (8/22) - Civil Penalty Assessment Death/Serious Injury/Physical Abuse (Child Care), LIC 421D (CRP) (6/17) - Civil Penalty Assessment Death/Serious Bodily Injury/Physical Abuse (CRP), LIC 421FC (7/17) - Civil Penalty Assessment Failure To Correct And Repeat Violations, LIC 421IM (7/17) - Civil Penalty Assessment Immediate $500 And Repeat Violations, LIC 422 (9/11) - Notice Of Civil Penalties Due, LIC 424 (1/03) - Record Of Client's Cash Resources For Change Of Licensee, LIC 503 (3/99) - Health Screening Report - Facility Personnel, LIC 507 (1/00) - Facilities Staff Work Schedule, LIC 508 (7/21) - Criminal Record Statement & Out-Of-State Disclosure, LIC 508 O-O-S (2/20) - Out-Of-State Disclosure, LIC 508A (3/11) - Criminal Record Statement - Adoption Facilitator, LIC 508B (3/11) - Criminal Record Statement - Long-Term Care Ombudsman Program, LIC 508D (11/22) - Out-Of-State Disclosure And Criminal Record Statement, LIC 601 (8/08) - Identification And Emergency Information, LIC 602 (7/22) - Physician's Report For Community Care Facilities, LIC 602A (8/11) - Physician's Report For Residential Care Facilities For The Elderly (RCFE), LIC 603 (6/22) - Preplacement Appraisal Information, LIC 604 (10/05) - Admission Agreement Guide For Residential Facilities, LIC 604A (2/05) - Admission Agreement For Residential Care Facilities For The Elderly, LIC 605A (7/22) - Release Of Client/Resident Medical Information, LIC 606 (8/18) - Residential Care Facility For The Elderly Disclosure Worksheet, LIC 610 (10/03) - Emergency Disaster Plan For Child Care Centers, LIC 610A (01/22) - Emergency Disaster Plan For Family Child Care Homes, LIC 610B (6/02) - Emergency Plan For Foster Family Homes, LIC 610C (10/03) - Emergency Disaster Plan For Children's Residential Facilities (Except Foster Family Homes), LIC 610D (12/21) - Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities, LIC 610E (3/19) - Emergency Disaster Plan For Residential Care Facilities For The Elderly, LIC 613 (12/02) - Personal Rights Adult Residential Care Facilities, LIC 613A (8/08) - Personal Rights - Child Care Centers, LIC 613B (6/22) - Personal Rights Childrens Residential Facilities, LIC 613C (1/19) - Personal Rights Of Residents In Publicly Operated Residential Care Facilities For The Elderly, LIC 613C-2 (1/19) - Personal Rights Of Residents In Privately Operated Residential Care Facilities For The Elderly, LIC 621 (4/99) - Client/Resident Personal Property And Valuables, LIC 622 (9/19) - Centrally Stored Medication And Destruction Record, LIC 622A (6/17) - Medication Administration Record (MAR), LIC 622B (5/17) - Psychotropic Medication Administration Record (MAR), LIC 623 (5/01) - Group Planned Activities, LIC 624 (4/99) - Unusual Incident/Injury Report, LIC 624B (8/08) - Unusual Incident/Injury Report - Family Child Care Home, LIC 624 LE (12/22) - Law Enforcement Contact Report, LIC 625 (11/19) Appraisal/Needs and Services Plan, LIC 627 (9/08) - Consent For Emergency Medical Treatment - Child Care Centers Or Family Child Care Homes, LIC 627A (9/08) - Consent To A Medical Examination, LIC 627B (9/08) - Consent For Emergency Medical Treatment - Children's Residential Facilities, LIC 627C (4/00) - Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities, LIC 700 (10/19) - Identification And Emergency Information Child Care Centers/Family Child Care Homes, LIC 701 (8/08) - Physician's Report - Child Care Centers, LIC 701A (9/00) - Gastrostomy - Tube Care: Physician's Checklist (Child Care Facilities), LIC 701B (9/00) - Gastrostomy - Tube Care Consent/Verification (Child Care Facilities), LIC 702 (10/19) - Child's Preadmission Health History - Parent/Authorized Representative Report, LIC 808 (12/20) Plan For Epidemic Outbreak Specific to COVID 19 Mitigation Plan Report, LIC 809 (12/15) - Facility Evaluation Report, LIC 812 (8/06) - Detail Supportive Information, LIC 813 (11/99) - Facility Photography Report, LIC 856A (3/21) - Complaint Intake Notification, LIC 856B (3/21) - Complaint Determination Notification - Substantiated, LIC 856C (3/21) - Complaint Determination Notification - Unsubstantiated, LIC 856D (3/21) - Complaint Determination Notification - Unfounded, LIC 857 (8/06) - Children's Record Review, LIC 858 (10/99) - Client/Resident Records Review, LIC 858A (7/00) - Additional Child Records Review For Specialized Foster Care Homes, LIC 859 (8/06) - Review of Staff/Volunteer, LIC 860C (12/02) - Facility Review Index Foster Family Homes, LIC 861 (1/03) - Prelicensing In-Home Interview, LIC 907 (5/00) - Transmittal For Processing, LIC 972 (5/00) - Individual Waiver/Exception Log, LIC 973 (4/03) - Documented Alternative Plan - Foster Family Homes (Bedrooms), LIC 974 (4/03) - Documented Alternative Plan - Foster Family Homes (Telephones), LIC 986A (10/99) - Notice Of Revocation Action, LIC 989A (3/17) - Non-Confidential Records Request Form, LIC 995 (9/08) - Child Care Center - Notification Of Parents' Rights, LIC 995A (8/08) - Family Child Care Home - Notification Of Parents' Rights, LIC 995B (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Removal/Exclusion), LIC 995C (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Reinstatement), LIC 995D (5/03) - Family Child Care Home Explanation Of Removal/Exclusions And Reinstatement, LIC 995E (10/09) - Important Information For Parents, LIC 995F (10/09) - Caregiver Background Check Information, LIC 996 (5/99) - Agreement For Licensure Of Community Care Facility/Child Care Facility On Federal Property, LIC 996A (5/01) - Agreement For Licensure Of Community Care Facility/Child Care Facility On Indian Reservations, LIC 997 (10/99) - Agreement By Licensee/Applicant On Federal Property, LIC 997A (4/01) - Agreement By Licensee/Applicant On Indian Reservations, LIC 999 (3/99) - Facility Sketch (Floor Plan), LIC 999A (2/05) - Facility Sketch (Floor Plan) - Family Child Care Home, LIC 9011A (4/05) - County Licensing Administrative Action Personnel Flagging Attachment, LIC 9011B (5/05) - CDSS Licensing Administrative Action Personnel Flagging Attachment, LIC 9020 (5/17) - Register Of Facility Clients/Residents, LIC 9020A (6/17) - Register Of Facility Residents - Residential Care Facilities For The Elderly, LIC 9029B (7/09) - Statement Of Facts Preparation Checklist, LIC 9031 (11/99) - Notice Of Temporary Suspension Order Of License, LIC 9040 (10/05) - Child Care Facility Roster, LIC 9054 (3/99) - Local Fire Inspection Authority Information, LIC 9058 (3/22) - Applicant/Licensee Rights, LIC 9059 (5/99) - Personal Property Procedures, LIC 9060 (2/00) - Resident Theft And Loss Record, LIC 9092 (2/11) - Fire Pre-Inspection/Consultation Request, LIC 9095 (6/99) - Evaluation Of Teacher Qualifications, LIC 9096 (2/00) - Evaluation Of Director Qualifications, LIC 9099 (12/16) - Complaint Investigation Report, LIC 9102TA (2/19) - Advisory Notes - Technical Assistance, LIC 9102TV (2/19) - Advisory Notes - Technical Violation, LIC 9106 (11/19) - Group Home Program Statement General Instructions, LIC 9106A (3/21) - Short-Term Residential Therapeutic Program, LIC 9108 (3/05) - Statement Acknowledging Requirement To Report Suspected Child Abuse, LIC 9111 (12/99) - Noncompliance Conference Summary, LIC 9112 (9/21) - Facility Compliance Plan, LIC 9118 (6/21) - Facility Inspection Checklist Checklist Child Care Centers, LIC 9119 (10/22) Facility Inspection Checklist Group Homes, LIC 9119 AA (7/22) - Facility Inspection Checklist Adoption Agency, LIC 9119 CCH (11/22) - Facility Inspection Checklist Community Crisis Home, LIC 9119 CN (8/22) - Facility Inspection Checklist Crisis Nurseries, LIC 9119 CTF (1/22) Facility Inspection Checklist Community Treatment Facility, LIC 9119 EBSH (4/22) - Facility Inspection Checklist Enhanced Behavioral Supports Homes, LIC 9119 TrSCF (12/22) - Facility Inspection Checklist Transitional Shelter Care Facility, LIC 9119 YHPC (4/22) - Facility Inspection Checklist Youth Homelessness Prevention Center, LIC 9120A (2/20) - Licensed Facility Inspection Checklist Adult Care Facilities, LIC 9121 (7/21) - Facility Visit Checklist Family Child Care, LIC 9122 (11/03) - Facility Visit Checklist Foster Family Home, LIC 9122A (7/20) Facility Inspection Checklist Small Family Home, LIC 9123 (2/20) - FacilityInspection Checklist - Residential Care Facility For The Elderly, LIC 9128 (5/22) - Foster Family Agency Program Statement, LIC 9139 (11/16) - Renewal Of Continuing Education Course Approval - Administrator Certification Program, LIC 9140 (11/16) - Request For Course Approval - Administrator Certification Program, LIC 9140A - Request to Add or Replace Instructor, LIC 9148 (9/00) - Earthquake Preparedness Checklist (EPC), LIC 9149 (8/14) - Family Child Care Home Property Owner/Landlord Consent Form, LIC 9150 (8/14) - Parent Notification - Additional Children in Care, LIC 9151 (8/14) - Property Owner/Landlord Notification Family Child Care Home, LIC 9158 (7/22) - Telecommunications Device Notification, LIC 9163 (3/21) - Request Live Scan Service - Community Care Licensing, LIC 9163B (11/22) - Request Live Scan Service - Long Term Care OMBUDSMAN, LIC 9165 (4/22) - Board Of Director Statement, LIC 9166 (2/01) - Nebulizer Care Consent/Verification (Child Care Facilities), LIC 9172 (8/01) - Functional Capability Assessment, LIC 9182 (1/23) - Criminal Background Clearance Transfer Request, LIC 9185 (8/08) - Foster Family Agency Certified Home, LIC 9187 (7/00) - Child Care Client Death Report, LIC 9188 (12/22) - Criminal Record Exemption Transfer Request, LIC 9198 (7/01) - Modified Comprehensive Visit Licensee Self-Assessment Staff Qualifications/Records Module Child Care Centers, LIC 9199 (7/01) - Modified Comprehensive Visit Licensee Self-Assessment Children's Records Module Child Care Centers, LIC 9200 (9/11) - Pre-Licensing Facility Evaluation Checklist, LIC 9201 (10/01) - Annual Regulation Compliance Checklist, LIC 9210 (5/06) - Quarterly County Exemption Report, LIC 9211 (9/21) - Request For Inactive Child Care License Status, LIC 9212 (10/05) - Consumer Awareness Information - Family Child Care, LIC 9213 (1/04) - Notice Of Site Visit By A Child Care Licensing Office Representative, LIC 9214 (12/22) - Application for Administration Certification - Administrator Certification Program, LIC 9216 (3/17) - Complaint And Type A Violation Log, LIC 9217 (5/22) - Pre-Licensing Readiness Guide - Family Child Care Home, LIC 9219 (3/16) - Crisis Nursery Monthly Report, LIC 9219A (3/16) - Crisis Day Care Sign-In, LIC 9221 (5/22) - Parent Consent For Administration Of Medications And Medication Chart, LIC 9222 (9/05) - Blood Glucose Testing Consent/Verification Child Care Facilities, LIC 9223 (4/17) - Child Care Advocate Program, LIC 9224 (8/08) - Acknowledgement Of Receipt Of Licensing Reports, LIC 9225 (4/10) - Pre-Placement Questionnaire, LIC 9226 (5/18) - Request For Training Approval: Mandated Child Abuse Reporter Training, LIC 9227 (8/20) - Individual Infant Sleeping Plan, LIC 9229 (7/21) - Licensing Program Manager (LPM) Checklist For Complaint Review, LIC 9230 (7/21) - Licensing Program Analyst (LPA) Checklist For Complaint Review, LIC 9233 (7/20) Facility Inspection Checklist Foster Family Agencies, LIC 9234 (7/20) Entrance Checklist Foster Family Agency, LIC 9235 (10/22) Facility Inspection Checklist Short Term Residential Therapeutic Program, LIC 9236 (7/20) Entrance Checklist Short Term Residential Therapeutic Program, LIC 9237 (7/20) Facility Inspection Checklist Transitional Housing Placement Program, LIC 9238 (7/20) Entrance Checklist Transitional Housing Placement Program, LIC 9239 (7/20) Entrance Checklist Group Home, LIC 9239 AA (12/22) Entrance Checklist Adoption Agency, LIC 9239 CCH (11/22) - Entrance Checklist - Community Crisis Homes, LIC 9239 CN (8/22) - Entrance Checklist - Crisis Nurseries, LIC 9239 CTF (01/22) - Entrance Checklist Community Treatment Facility, LIC 9239 EBSH (3/22) - Entrance Checklist Enhanced Behavioral Supports Homes, LIC 9239 TrSCF (8/22) - Entrance Checklist - Transitional Shelter Care Facility, LIC 9239 YHPC (4/22) - Entrance Checklist Youth Homelessness Prevention Center, LIC 9240 (7/20) Entrance Checklist Small Family Home, LIC 9241 (2/20) - Entrance Checklist Adult Care Facilities, LIC 9242 (9/19) - Entrance Checklist Residential Care Facilities For The Elderly, LIC 9263 (3/21) Form 1-1: Resident Population, LIC 9264 (3/21) Form 1-2: Annual Provider Fee, LIC 9265 (6/21) Form 5-1: Long-Term Debt Incurred In A Prior Year (Including Balloon Debt), LIC 9266 (3/21) Form 5-2: Long-Term Debt Incurred During Fiscal Year (Including Balloon Debt), LIC 9267 (3/21) Form 5-3: Calculation Of Long-Term Debt Reserve Amount, LIC 9268 (6/21) Form 5-4: Calculation Of Net Operating Expenses, LIC 9269 (3/21) Form 5-5: Annual Reserve Certification, LIC 9270 (9/22) Form 7-1: Report On CCRC Monthly Care Fees, LIC 9271 (6/21) Form 9-1: Calculation Of Refund Reserve Amount, LIC 9272 (11/21) Annual Report Checklist, LIC 9273 (5/22) Continuing Care Retirement Community Disclosure Statement, LIC 9275 (6/21) - External Water Sampler Self-Certification Form, LIC 9276 (7/21) Child Care Center Sampling Checklist Form, IC 9277LUA (8/21) - Guardian Licensee User Access Form, LIC 9279 (10/21) - Pre-licensing Entrance Checklist - Child Care Centers, LIC 9280 (10/21) - Pre-licensing Entrance Checklist - Family Child Care Homes, LIC 9281 (01/22)- Small Family Home Risk Assessment, LIC 9282 (5/22) Residential Infection Control Plan - Adult Residential Facilities, Enhanced Behavioral Supports Homes, Community Crisis Homes, Residential Care Facilities for the Elderly, Residential Care Facilities for the Chronically Ill, and Social Rehabilitation Facilities, LIC 9283 (5/22) - Infection Control Plan - Adult Day Programs. 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