California Department of Social Services

The LIC 9283 form is an Infection Control Plan specifically developed for Adult Day Programs regulated by the California Department of Social Services. This plan provides guidance and procedures for preventing and managing infections within adult day program settings. It includes measures such as hand hygiene practices, cleaning and disinfection protocols, respiratory etiquette, staff training requirements, participant education, health screening procedures, and outbreak response plans.

Form LIC 9052 is used to provide notice of employee rights in licensed facilities in California. The form is completed by facility administrators or human resources personnel and outlines various employment rights and protections afforded to employees. It covers topics such as minimum wage, overtime pay, meal and rest breaks, anti-discrimination policies, workplace safety, and other relevant employment regulations.

Form LIC 9060 is used to document incidents of theft or loss involving residents' personal property in licensed facilities in California. The form is completed by facility staff and includes details such as the resident's name, date of incident, description of the item(s) involved, estimated value, circumstances surrounding the theft or loss, and any relevant actions taken.

Form LIC 9020 is used to maintain a register of clients or residents in licensed facilities in California. The form is completed by facility staff and includes essential information such as the client's or resident's name, date of admission, date of discharge if applicable, identification numbers, and other relevant details. By utilizing this form, facilities can keep accurate records of individuals served, track admissions and discharges, ensure compliance with occupancy limits, and provide necessary information for planning and reporting purposes.

Form LIC 9040 is used to maintain a roster of children enrolled in child care facilities in California. The form is completed by facility staff and includes information such as each child's name, date of birth, parent/guardian contact information, emergency contacts, authorized pick-up persons, and any relevant medical or allergy information. By utilizing this form, child care facilities ensure accurate record-keeping, track attendance, support communication during emergencies, and comply with licensing regulations related to child care administration.

Form LIC 401 is used by licensed facility operators in California to provide a monthly operating statement detailing the financial aspects of their operations. The form requires the disclosure of revenue, expenses, investments, reserves, and other financial information necessary for evaluating the financial health and stability of the facility.

By utilizing this form, facility operators maintain transparent financial records, enable proper financial management, and fulfill reporting obligations to the California Department of Social Services (CDSS).

Form LIC 301 is used to request references for individuals seeking employment or volunteer positions in licensed facilities. The form is completed by the California Department of Social Services (CDSS) or the facility operator to gather information about an individual's character, work history, qualifications, and suitability for the position applied for. By utilizing this form, the CDSS or the facility operator collects valuable insights from references to make informed decisions regarding the individual's suitability for employment or volunteer roles.

Form LIC 229 is a certificate of approval issued by the California Department of Social Services (CDSS). This form signifies that a facility or program has met the necessary licensing requirements and has been granted approval to operate. The certificate contains relevant details such as the facility's name, address, license number, and the effective date of approval. The LIC 229 form serves as official documentation demonstrating compliance with licensing standards and authorizes the facility or program to provide services in accordance with applicable regulations.

Form LIC 602 is a physician's report used for community care facilities in California. The form is completed by a licensed physician and provides detailed information about the health conditions and medical needs of individuals residing or receiving care in the facility. It includes assessments of physical and mental health, medication administration requirements, specialized treatments, and any specific recommendations for care.

Form LIC 300A is used to confirm the removal of a child from a licensed facility and request an exemption from further licensing requirements. The form is completed by the licensee or facility operator to notify the California Department of Social Services (CDSS) about the removal of a child from their care. By utilizing this form, the licensee seeks an exemption from certain licensing provisions that may no longer apply due to the child's removal from the facility.