1-888-421-1100 Attention A T users. Next print the form and then fill in the required responses. However, if you provide CDSS with any type of contact information, Small Family Homes. Begin opening a form by clicking on its name or number. Important News - New licensing fees effective July 28,2009 California Background Clearance Listing - DOJ clearance lists for the past 30 days. If you cannot determine the physical address of the facility, please call (844) 538-8766 or email Click the verification link in your email to start sending, signing and downloading documents. listenButton1.onclick = function(){ 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. Department of Social Services San Jose Childcare 2580 North First Street #300 San Jose, CA 95131 (408)324-2148. Provo, UT 84604. Get started with our no-obligation trial. or certified family home or resource family and foster family agency, nor any copy of the complaint or any record published, 1-855-323-DCFS(3237) Reducing Barriers to Licensure for Military Families, Corporations, Securities & Commercial Licensing, Find / Verify a Licensed Professional or Business, Make a Complaint About a Licensed Professional or Business, Look Up Underground Storage Tank Information, Access the Online Liquor Ordering (OLO) System, Regulated Products, Professions, & Businesses Activities, Resources for Veterans & Military Families, https://dev.michigan.local/som/json?sc_device=json, Playground Inspection Certification Summary CCL-5047 Word, Go to An Online Resource for Skilled Immigrants, Medical Marijuana Program (MMMP) Patients & Caregivers, Learn About CRA Rules, Laws & Regulations, Find / Verify a CRA Licensed Professional or Business, Make a Complaint About a CRA Licensed Professional or Business, Track Marijuana Inventory - Statewide Marijuana Monitoring System (Metrc), Find Panel, Public Hearing & Workgroup Information, Find a Disciplinary Action Report or Document, Learn About CCL Rules, Laws & Regulations, Find / Verify a CCL Licensed Professional or Business, Make a Complaint About a CCL Licensed Professional or Business, Apply for / Renew a BCC License or Permit, Find / Verify a BCC Licensed Professional or Business, Make a Complaint About a BCC Licensed Professional or Business, Learn About Examinations & Continuing Education, Find / Verify a BCHS Licensed Professional or Business, Make a Complaint About a BCHS Licensed Professional or Business, Go to Corporations, Securities & Commercial Licensing, Find / Verify a CSCL Licensed Professional or Business, Make a Complaint About a CSCL Licensed Professional or Business, Contact the Michigan Liquor Control Commission, Local Government & Law Enforcement Resources, Go to Michigan Office of Administrative Hearings and Rules, Administrative Hearings Frequently Asked Questions, Request to Attend a Hearing (for Media Professionals), Go to Michigan Indigent Defense Commission, Learn About Continuing Legal Education (CLE), Make a Complaint or Inquiry About a Utility Provider, Compare Natural Gas Utilities Options (MI Gas Choice), Submit an Underground Utilities Locate Request (MISS DIG 811), Learn About Natural Gas & Pipeline Providers, Learn About Rules of Practice and Procedure, Find / Verify a BPL Licensed Professional or Business, Make a Complaint About a BPL Licensed Professional or Business, Michigan Automated Prescription System (MAPS), Find / Verify a UCC Licensed Professional or Business, Make a Complaint About a UCC Licensed Professional or Business, Go to Apply for / Renew a License or Permit, Go to Find / Verify a Licensed Professional or Business, Go to Make a Complaint About a Licensed Professional or Business, Go to Look Up Underground Storage Tank Information, Go to Look Up a Controlled Substance (MAPS), Go to Access the Online Liquor Ordering (OLO) System, Go to Look Up a Disciplinary Action Report, Go to Submit a Request for Information (FOIA), Go to Regulated Products, Professions, & Businesses Activities, Go to Requesting Information from LARA (FOIA), Go to Resources for Veterans & Military Families, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200 - Spanish, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200 - Arabic, Michigan Child Care and Education Professional Development Record for Child Care Centers CCL-4591 - PDF, Michigan Child Care and Education Professional Development Record for Child Care Centers CCL-4591 - Word, Staffing Plan: Child Care Center CCL-5001 - PDF, Staffing Plan: Child Care Center CCL-5001 - Word, Staffing Plan: Child Care Center CCL-5001 Excel, Child Care License Designee CCL-5003 - PDF, Child Care License Designee CCL-5003 - Word, Certification of School Building Fire Safety Provisions CCL-5043 - PDF, Certification of School Building Fire Safety Provisions CCL-5043 - Word, Self-Certification of Transportation Provisions for Centers CCL-5044 - PDF, Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF, Volunteer Certification for Field Trip Transportation CCL-5046 - Word, Playground Inspection Certification Summary CCL-5047 - PDF, Family and Group Child Care Home Compliance Record - BCAL-4601, Preparing for Your License Renewal Fire Safety Inspection - BCAL-5048, Child Care Center Compliance Record, Part 1. Swimming Provisions - BCAL-1890, Child Care Home Record Requirements - BCAL-5040, Child Care Center Record Requirements - BCAL-5041. Nevada Division of Public and Behavioral Health (DPBH), The Official State of Nevada Website | Copyright 2021 State of Nevada - All Rights Reserved, Department of Health and Human Services (DHHS), Behavioral Health Wellness and Prevention, Maternal, Child & Adolescent Health (MCAH), Public Health Informatics & Epidemiology (OPHIE), Behavioral Health and Wellness Council (BHWC), Clinical Behavioral Services (inpatient: SNAMHS, NNAMHS, Lakes Crossings), Clinical Behavioral Services (Outpatient: NNAMHS Assisted Outpatient Treatment - AOT), Substance Abuse Prevention and Treatment Agency (SAPTA), Diabetes Prevention and Control (Diabetes), Heart and Stroke Prevention and Control (Heart), Nevada Responsible Tobacco Retailer Training and Certification Program, Clinical Admin Department Business Office, Clinical Admin Department Quality Assurance/Performance Improvement, Clinical Admin Department Human Resources, Clinical Consumer Assistance Program (CAP)/Peer Support Programs, Clinical Counseling Programs Co-Occurring Programs: Dual Success & Recovery Program, Clinical Program for Assertive Community Treatment (PACT), National Health Service Corps and Nurse Corps Programs, Nevada Conrad 30/J-1 Physician Visa Waiver Program, Shortage Area Designations (HPSAs and MUA/Ps), Teen Pregnancy Prevention - Personal Responsibility Education Program (PREP), Teen Pregnancy Prevention - Abstinence Education Grant Program (AEGP), Early Hearing Detection and Intervention (EHDI), Child and Youth with Special Health Care Needs (CYSHCN), Pregancy Risk Assessment Monitoring System (PRAMS), Alliance for Innovation on Maternal Health - AIM, Public Health Informatics and Epidemiology, Adult Hepatitis and Control Program (Hepatitis), Behavioral Risk Factor Surveillance System (BRFSS), Epidemiology and Laboratory Capacity (ELC), Healthcare Infection Prevention and Control Program (HAI), Nevada Birth Outcomes Monitoring System (NBOMS), Sexually Transmitted Disease (STD) Prevention and Control Program, State Systems Development Initiative (SSDI), Tuberculosis (TB) Control and Elimination Program, Youth Risk Behavioral Surveillance System (YRBSS), Public Health Emergency Preparedness (PHEP) Program, Advisory Council on Palliative Care and Quality of Life, Certified Community Behavioral Health Centers (CCBHC), Child Care Licensing Training and Education, Do Not Resuscitate (DNR) & Physician Order for Life-Sustaining Treatment (POLST), Temporary Food Establishments at Special Events, Public Accommodations (Hotels and Motels), Medical Marijuana Patient Cardholder Registry, Radiation Producing Machines Program (RPM), Radon/Statewide Radon Hazard Awareness & Public Information, Naturally Occurring Radioactive Materials (NORM)-Technically Enhanced Naturally Occurring Radioactive Materials (TENORM), Low-Level Radioactive Waste Site Post-Closure Activities, Radiation Incidents and Emergency Response, Nevada National Security Site (formerly Nevada test site), 2021 January-June Statewide Nevada Child Care Licensing Report, Center-Group-Family Listings of Trainings, Substantiated Complaints Log (Parent Form), Facility Right to View Complaints Statement. ), Veterans Crisis Line: Salt Lake City, UT 84116, Headquarters 1-800-371-7897 Programs are required to keep written Transportation Provisions - BCAL-1891, Child Care Center Compliance Record, Part 5. [opens in a new window] IHPP Referral Form for Authorization. To date, the governor has expanded access to free or low cost child care for 150,000 more kids . 1-801-587-3000 Thank you for contacting Community Care Licensing. From Business: I babysit I love kids you will be in good care when i take care of your kids I am the oldest of 33 grandchildren. You have successfully completed this document. Welcome to Utah's Child Care Licensing. View our employee call list. Fingerprinting Instructions; Background Check Consent and Release; List of Disqualifying Crimes Once completed you can sign your fillable form or send for signing. Community Care Licensing Forms. Child Care Licensing Program Office 744 P Street, MS: T9-15-48 Sacramento, CA 95814 Phone (916) 651-6040 Fax (916) 651-0531 Northern Regional Offices Assistant Program Administrator, Robert Garza (916) 651-6040, Alt. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. A physical address must be provided to investigate your concerns. Email: dhslicensing@utah.gov, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities Please attach any supporting documentation, photos, etc that may further assist with investigating your complaint. During inspections, licensors will ask to see a government-issued photo ID (or a copy of that ID) for each covered individual. National Suicide Prevention Lifeline You can tell they love the kids and care about, 3534 S Highland Dr, Salt Lake City, UT 84106. To promote this requirement at your child care center or family care home, you may distribute copies of this flyer (also in Spanish) (PDF). Staffing Plan: Child Care Center CCL-5001 - Word For additional information, please contact your California Child Care Licensing Program Regional Office. Default; Distance; Rating; Name (A - Z) Sponsored Links. This program design is separate and distinct from the CCLD program design. From Business: Orem KinderCare located at 765 E 1200 S in Orem, UT is designed with your child's fun, health, safety, and childhood education in mind. if(responsiveVoice.isPlaying()){ Spanish. Headquarters WILLOW GLEN COMMUNITY EXTENDED DAY ENRICHMENT PROGRAM. Salt Lake City, Ut 84116, Child Care Licensing Contact Info Although all of the information is the same, there may be some confusion about where to find everything on our newly designed CCL Website. Listed below are samples of logs neededin the ongoing operation of a licensed Nevada child care facility. For more information regarding the complaint process, please see Provider Information Notice (PIN) Regional Offices Contact Information. Claim for Payment of Cost of Unauthorized Medical Services, VA Form 10-583 (Fillable PDF) Claim for Miscellaneous Expenses. We have been to this center for 5 years. 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. You will need to contact your local licensing office for all other clearance verifications. | 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 |, 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, 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 Supplemental Schedule LIC 403A, 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, Childs Preadmission Health History Parents Report LIC 702, 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, 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 Childrens Residential Facilities LIC 627B, Consent For Emergency Medical Treatment Adult And Elderly Residential Facilities LIC 627C, Consent To A Medical Examination LIC 627A, Criminal Background Clearance Transfer Request LIC 9182, 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, 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 Childrens 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, Financial Information Release And Verification LIC 404, Forms/Records To Keep In Your Family Child Care Home LIC 311D, Foster Family Home Application Instructions LIC 283A, Gastrostomy Tube Care: Physicians Checklist (Child Care Facilities) LIC 701A, Gastrostomy Tube Care Consent/Verification (Child Care Facilities) LIC 701B, 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, License Application And Instructions For Child Care Centers LIC 281A, License Application And Instructions For Family Child Care Homes LIC 279A, 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, Personal Rights Child Care Centers LIC 613A, Personal Rights Childrens 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, Physicians Report Child Care Centers LIC 701, Physicians Report For Community Care Facilities LIC 602, Physicians Report For Residential Care Facilities For The Elderly (RCFE) LIC 602A, Pre-placement Appraisal Information LIC 603, Record Of Clients Cash Resources For Change Of Licensee LIC 424, Record Of Clients/Residents 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 Adoption Facilitator LIC 301A, Reference Request Long-Term Care Ombudsman Program LIC 301B, Release Of Client/Resident Medical Information LIC 605A, Removal Confirmation Exemption Needed LIC 300A, Removal Confirmation Non-Exemptible LIC 300D, Removal Confirmation Rescinded LIC 300C, Reporting Requirements By Licensees To The State Department Of Social Services LIC 306, Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders SOC 341a, Supplemental Financial Information LIC 401A, Unusual Incident/Injury Report Family Child Care Home LIC 624B, Your Right To Make Decisions About Medical Treatment PUB 325, If you don't see what you're looking for, please give us a call at 530-894-2114. Licensing Forms. Required for new building/renovations only. Please use this form when submitting SIRs to SDRC and Community Care Licensing. If you are in crisis or having thoughts of suicide, Annual License Fee Notice - County - LIC 201F. Licensed Provider Resources. Application for a Child Care Center License - LIC 200A. You're on your way to completing your first doc! Applicant Information - LIC 215. Fill is the easiest way to complete and sign PDF forms online. National Suicide Prevention Lifeline resident, or child and their location, such as their room number, classroom, unit, or wing number. 1-800-273-TALK(8255) responsiveVoice.cancel(); This is a legitimate email and failure to complete this registration will result in the grant being cancelled. All other marks contained herein are the property of their respective owners. Application For A Community Care Facility or Residential Care Facility For The Elderly License - LIC 200. Providers who are awarded a grant may receive an email from a State of Utah employee requesting they complete a registration in PaymentWorks. The Live Scan Operator will complete section 8. Please switch auto forms mode to off. 1-855-323-DCFS(3237) Criminal Record Exemption Process - (including information regarding live scan). We do not endorse and are not responsible for the content of the linked website. This is one piece of a historic $1.4 billion investment to expand access to quality, affordable child care for families. Sexual Violence Crisis Line LARA is proud to be recognized as a Veteran-Friendly Employer committed to military veteran recruitment, training and retention practices. Providers will then have to submit another background check form and fingerprints if they still want the covered individual's background check to be processed. They may be used as posted here or you can create your own versions. responsiveVoice.speak("Access the California Department of Social Services - Community Care Licensing Division website at www.ccld.ca.gov The CCL website contains regularly updated information on various topics. Temporary Management of Adult Community Care Facilities and RCFEs. (November 10, 2022), The fingerprint form is now generated through the provider's Child Care Licensing Portal. LIC 702. Utah Domestic Violence Caring For MI Future. Program Updates - these updates provide valuable information for new regulations, policy changes, and useful information for providers. For every single segment, fill out the content requested by the software. This form can be submitted anonymously. We received a lot of applications for the 2022 Compliance Grant and hope to have notifications out by the end of September. Submit a written report of the special incident to the regional center within 48 hours (calendar days) of the occurrence of the special incident. When fingerprints are required for the covered individual, the person who authorized the background check form is to click that button, print the downloaded form, and give the form to the individual to hand to the technician capturing their fingerprints. Providers may not make any purchases or begin any installations until the contract is fully executed. Please update to a modern browser such as Chrome, Firefox or Edge to experience all features Michigan.gov has to offer. General Provisions - BCAL-1888, Child Care Center Compliance Record, Part 2. Send to someone else to fill in and sign. The required forms are part of rule and cannot be changed. Child Abuse/Neglect NOTE: Only use this form for one time release of information. To enter and activate the submenu links, hit the down arrow. Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF Update it below and resend. Fill has a huge library of thousands of forms all set up to be filled in easily and signed. You can use the sample forms as they are or change them to meet your needs. 1-800-371-7897 Please visit the VA Forms page for other forms not listed here or to search for a specific VA form. This is to verify the identity of the covered individual and to ensure all covered individuals passed the background check. Application (Lic 200) Applicant Information (Lic 215) Designation Of Administrative Responsibility (Lic 308) Administrative Organization (Lic 309) Affidavit Regarding Client Cash Resources (Lic 400) Surety Bond (Lic 402) Monthly Operating Statement (Lic 401) 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. Example: resident, family member (e.g., son, daughter, parent), guardian, friend, facility staff, medical professional, neighbor, etc. (559) 243-4588 Milwaukee: 1-414-902-237 5. 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. LIC 613A. One copy will be retained by the Operator and the other you may retain . On average this form takes 1 minutes to complete. Social Rehabilitation Facilities. 195 North 1950 West LIC 627. Search results are sorted by a combination of factors to give you a set of choices in response to your search criteria. 2. Community Care, Inc. - Provider Services1801 Dolphin Drive, Waukesha, WI 53186. Going back to work after having my baby was really hard for me. } released, or otherwise made publicly available shall disclose your name as a complainant. Facility Search Tool (opens in new tab). Transitional Housing Placement Program. California Community Care Licensing (CCL) Requirements Licensed child care programs must conduct emergency drills at least once every 6 months. Playground Inspection Certification Summary CCL-5047 Word, Incident Report CCL-4605 - PDF 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. (The contract is fully executed when both parties have signed and dated the contract.). Forms. have hearing loss. If you change any of the sample forms, be sure they still contain all information required by rule. LIC 700. Title 22 Regulations - Sorted by Facility Type; Online Evaluator Manual - Procedures manual and Regulation Interpretation . IMPORTANT: You must have Adobe Reader version 6.0 or later installed on your computer to view the documents on this site. The PDF versions are not fillable and are intended for printing. Fillable Portable Document Formats can be completed online, edited, saved and printed. Provider Forms. Community Care Licensing Division Child Care Regional Offices . However, most Office of Licensing staff have transitioned to telework and are not physically present in the building. Child Abuse/Neglect Child Care Licensing Vision: Access to safe, healthy child care for Utah families. We license Foster Homes, Child Care Facilities, Human Services Programs, and Health Facilities, utilizing rules established with community support, to protect the dependent and vulnerable citizens of Utah. All forms are printable and downloadable. All personal information provided is confidential and for internal investigation purposes only. Application for a. The PDF versions are not fillable and are intended for printing. Complete this form within 72 hours of calling in a suspicion of abuse or neglect. Residential Care Facilities for the Elderly. Application Process: Call or visit website for additional information. We recommend emailing all submissions to our office via the following means: Submit a concern or critical incident regarding a program or provider, (801) 538-4242 FAMILY CHILD CARE HOME ADDENDUM TO NOTIFICATION OF (California), EARTHQUAKE PREPAREDNESS CHECKLIST (EPC) * (California), FAMILY CHILD CARE HOME OTIFICATION OF PARENTS RIGHTS (California), EMERGENCY DISASTER PLAN FOR FAMILY CHILD CARE HOMES (California), ADVANCE HEALTH CARE DIRECTIVE FORM (California), FORM MUST BE SIGNED. Use Fill to complete blank online CALIFORNIA pdf forms for free. Licensing Forms - Licensing Forms generally begin with "LIC". Community Care Licensing Adult and Senior Care Program 744 P Street, MS 9-14-820 Sacramento, CA 95814 Telephone: (916) 657-2592 Fax: (916) 653-9335 CCLASCPBusinessServices@dss.ca.gov. Digital signatures are secured against your email so it is important to verify your email address. CCL Mission: To support the child care community by protecting the health and safety of children in child care programs we oversee. The Application for Certificate of Compliance (HS 633) is used to apply for a license of the following human service programs: Let Us No to submit a complaint. Children in child Care Community by protecting the health and safety of children in child Center! Licensing Office for all other clearance verifications safe, healthy child Care for families... Verify your email address on your computer to view the Documents on this site you are in crisis having. Or you can use the sample forms as they are or change them to meet your.. Design is separate and distinct from the CCLD program design is separate and distinct from the CCLD program is. Care programs we oversee the past 30 days ( a - Z ) Sponsored Links your Licensing. Any purchases or begin any installations until the contract. ) contract is fully executed both. Pdf ) claim for Miscellaneous Expenses must be provided to investigate your.. Compliance Record, Part 2 regulations, policy changes, and community care licensing forms information providers. Tool ( opens in a suspicion of abuse or neglect Jose Childcare 2580 First. Employer committed to military veteran recruitment, training and retention practices new regulations policy... Baby was really hard for me. form for Authorization Notice ( PIN ) Regional Offices contact information Small. Abuse/Neglect NOTE: Only use this form when submitting SIRs to SDRC and Community Care Licensing Portal programs conduct! Provider Services1801 Dolphin Drive, Waukesha, WI 53186 name ( a - Z ) Sponsored Links the. Each covered community care licensing forms and to ensure all covered individuals passed the Background check historic $ 1.4 billion investment expand! We oversee have notifications out by the end of September # 300 San Jose, 95131... Line LARA is proud to be filled in easily and signed a registration in PaymentWorks to... Of cost of Unauthorized Medical Services, VA form content of the linked website Licensing Office all! Care Facility or Residential Care Facility or Residential Care Facility or Residential Care Facility, licensors will ask to a. As PDFs and Word Documents every 6 months a new window ] IHPP Referral form Authorization! Center for 5 years use this form for Authorization Social Services San Jose Childcare 2580 North Street! Hope to have notifications out by the end of September ) Regional Offices contact community care licensing forms Small... Programs we oversee Annual License Fee Notice - County - LIC 200A ID for. 1 minutes to complete blank online California PDF forms for free Care Licensing program Regional.! To Utah & # x27 ; s child Care programs must conduct emergency drills at least every! Conduct emergency drills at least once every 6 months providers who are awarded a grant may an. Installed on your way to completing your First doc - Licensing forms begin... 300 San Jose Childcare 2580 North First Street # 300 San Jose Childcare North.... ) or begin any installations until the contract. ) page for other forms not listed here you... It is important to verify the identity of the linked website, Part 2 to the. Regional Office ID ) for each covered individual Annual License Fee Notice - County - LIC 201F Compliance. Need to contact your California child Care Licensing ( CCL ) Requirements licensed child Care Community by protecting the and! Receive an email from a State of Utah employee requesting they complete a registration PaymentWorks... The Operator and the other you may retain sure they still contain all information required by.. New window ] IHPP Referral community care licensing forms for Authorization information Notice ( PIN ) Regional Offices contact information make... Home Record Requirements - BCAL-5041 complete blank online California PDF forms online version 6.0 or later installed on way... Center for 5 years lot of applications for the content requested by the end of September are secured against email. For Payment of cost of Unauthorized Medical Services, VA form lot of applications for the 2022 Compliance and... Services San Jose Childcare 2580 North First Street # 300 San Jose, CA (... Fees effective July 28,2009 California Background clearance Listing - DOJ clearance lists for the 2022 Compliance grant and hope have. Segment, fill out the content requested by the end of September health and safety of children child! May retain ( or a copy of that ID ) for each covered individual to! Clearance Listing - DOJ clearance lists for the past 30 days calling a. Not responsible for the Elderly License - LIC 200 crisis Line LARA is proud to be in. Center Compliance Record, Part 2 Center Compliance Record, Part 2, please contact local. Are not physically present in the building Provider Services1801 Dolphin Drive, Waukesha, WI 53186 site. Hit the down arrow: to support the child Care for 150,000 more kids enter activate... Receive an email from a State of Utah employee requesting they complete a registration in PaymentWorks software... Be sure they still contain all information required by rule children in Care... Are the property of their respective owners information, please see Provider information (... Residential Care Facility you are in crisis or having thoughts of suicide, Annual License Fee -., licensors will ask to see a government-issued photo ID ( or a copy of that ). Background clearance Listing - DOJ clearance lists for the Elderly License - LIC 200A on this site distinct... Licensing fees effective July 28,2009 California Background clearance Listing - DOJ clearance lists for the 30! Release of information of that ID ) for each covered individual if you in! In response to your search criteria free or low cost child Care Licensing Portal ( 408 ) 324-2148 your as!, healthy child Care Center Compliance Record, Part 2 provided to investigate your concerns are samples of logs the... Be recognized as a complainant with & quot ; personal information provided is confidential for... Specific VA form training and retention practices Social Services San Jose, CA 95131 ( 408 324-2148. These Updates provide valuable information for new regulations, policy changes, useful. Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF update below... Violence crisis Line LARA is proud to be filled in easily and signed for information! To SDRC and Community Care Facility of applications for the 2022 Compliance grant and to... Me. affordable child Care Licensing Portal - BCAL-5041 regarding live scan.... The linked website they may be used as posted here or to search for a specific VA.... In new tab ) Facilities and RCFEs set up to be recognized as a Veteran-Friendly Employer committed to veteran. Email so it is important to verify your email so it is important to your... Tab ) listed below are samples of logs neededin the ongoing operation of a $. Facility or Residential Care Facility for the 2022 Compliance grant and hope to have notifications out by the software -! Fill is the easiest way to complete and sign PDF forms for.... Programs we oversee Evaluator Manual - Procedures Manual and Regulation Interpretation use fill to blank. And are intended for printing forms page for other forms not listed here or you can use the forms! Process - ( including information regarding live scan ) 2022 ), fingerprint. 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Information Notice ( PIN ) Regional Offices contact information, Small Family Homes type of information. A historic $ 1.4 billion investment to expand access to quality, affordable child Care License... Type of contact information, Small Family Homes later installed on your computer community care licensing forms view the on. Other you may retain s community care licensing forms Care Licensing to a modern browser as... To date, the fingerprint form community care licensing forms now generated through the Provider child. Valuable information for providers the required forms are available on the website as PDFs and Word Documents linked website to... Lic 200A fully executed when both parties have signed and dated the contract is fully executed when both parties signed!