| 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. For more information regarding the complaint process, please see Provider Information Notice (PIN) If you continue to use your current browser then Fill may not function as expected. All other marks contained herein are the property of their respective owners. Submit a written report of the special incident to the regional center within 48 hours (calendar days) of the occurrence of the special incident. 195 North 1950 West Begin opening a form by clicking on its name or number. Providers may not make any purchases or begin any installations until the contract is fully executed. Please call with any questions or to connect with a Licensing staff member. IMPORTANT: You must have Adobe Reader version 6.0 or later installed on your computer to view the documents on this site. Salt Lake City, UT 84116. Licensing Forms - Licensing Forms generally begin with "LIC". Facility Search Tool (opens in new tab). }else{ Fee Payment Web Site. If known, include the name of the perpetrator, Please use this form when submitting SIRs to SDRC and Community Care Licensing. 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. Required for new building/renovations only. The Division of Licensing and Background Checks is comprised of the Office of Licensing and the Office of Background Processing. ADA Access: Please contact facility for accessibility information. Corporations, Securities & Commercial Licensing Bureau. : DIRECT DEPOSIT CALIFORNIA To (California), FACILITY SKETCH (Floor Plan) - Family Child Care (California), UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) (California), State of California Department of Insurance Live Scan (California), WG-012 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California), Retirement Allowance Estimate Request (California), ATTACHMENT TO PROOF OF ELECTRONIC SERVICE (PERSONS SERVED) (California), Form 2: FW-002 Request to Waive Additional Court (California), POS-050/EFS-050 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California), form to sign prior to submittal. To date, the governor has expanded access to free or low cost child care for 150,000 more kids . Child Care License Designee CCL-5003 - Word, Certification of School Building Fire Safety Provisions CCL-5043 - PDF Providers who are awarded a grant may receive an email from a State of Utah employee requesting they complete a registration in PaymentWorks. To promote this requirement at your child care center or family care home, you may distribute copies of this flyer (also in Spanish) (PDF). if(responsiveVoice.isPlaying()){ 1-855-323-DCFS(3237) 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. You will recieve an email notification when the document has been completed by all parties. Applicant Fingerprint Follow-Up Request - LIC 107. Then mail the document to the appropriate Office of Child Care Regional Licensing Office. Community Care, Inc. - Provider Services1801 Dolphin Drive, Waukesha, WI 53186. Please attach any supporting documentation, photos, etc that may further assist with investigating your complaint. Our analysts can investigate your complaint more thoroughly when sufficient details are provided. Complete this form within 72 hours of calling in a suspicion of abuse or neglect. GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING Instructions for the LIC 9163 1. . Use the links below to download these popular forms. The CCL website contains regularly updated information on various topics. You can pay fees here with a Visa, MasterCard, or with your debit card, if it has a Visa or MasterCard Logo. Mental Health Forms . We provide your child with an unsurpassed learning. View our employee call list. These forms are required for your renewal application. Administrator Certification Program - Information on approved vendors for all facility administrator programs. Title 22 Regulations - Sorted by Facility Type; Online Evaluator Manual - Procedures manual and Regulation Interpretation . Send to someone else to fill in and sign. This site explains the exemption process. The Live Scan Operator will complete section 8. Contact us and well get back to you soon. We have been to this center for 5 years. See reviews, photos, directions, phone numbers and more for Community Care Licensing locations in Provo, UT. Completing the transition to our new database is a priority. 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. Care in the Community. Our mailing address is: Office of Licensing 1-855-323-DCFS(3237) Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. Inc. - Provider Services1801 Dolphin Drive, Waukesha, WI 53186 - Provider Services1801 Drive! 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