California Department of Social Services

Form LIC 9188 is used to request the transfer of a criminal record exemption for individuals who have previously been granted an exemption to work or volunteer in care facilities in California. This form is typically used when an individual changes positions or moves to a different facility within the same organization. By completing this form, care facilities initiate the process of transferring the existing criminal record exemption, allowing the individual to continue their employment or volunteer service with the appropriate authorization.

Form LIC 9200 is used as a checklist during the pre-licensing evaluation of child care facilities in California. It provides a comprehensive list of items that need to be assessed and evaluated before granting a child care license. The form covers various aspects, including facility safety, health measures, staff qualifications, program policies, record-keeping practices, and compliance with licensing regulations.

Form LIC 9214 is used by individuals seeking administrator certification in the care facility setting in California. This form serves as an application for the Administrator Certification Program and collects information about the applicant's qualifications, experience, and educational background. By completing this form and submitting it to the appropriate authority, individuals initiate the process of obtaining administrative certification, which is often required for managerial positions in care facilities such as assisted living facilities or residential care homes.

Form LIC 9216 is used by care facilities in California to document complaints received and Type A violations identified within their operations. This form helps facilities maintain a record of complaints and violations, including details such as the nature of the complaint or violation, actions taken to address it, and any follow-up measures. By utilizing this form, care facilities demonstrate transparency, accountability, and a commitment to addressing concerns and maintaining compliance with licensing regulations.

The LIC 9230 form is similar to LIC 9229 but is specifically tailored for Licensing Program Analysts within the California Department of Social Services. This checklist provides guidance to Licensing Program Analysts during the review process of complaints filed against licensed facilities. It assists analysts in conducting a detailed assessment of the complaint, gathering necessary information, evaluating the facility's compliance with licensing regulations, and determining appropriate actions or resolutions.

Form LIC 9219 is used by crisis nurseries in California to submit monthly reports on their operations and activities. This form collects data related to the number of children served, services provided, staff-to-child ratios, utilization rates, and other relevant information. By submitting this report, crisis nurseries fulfill reporting requirements and contribute to the monitoring and evaluation of their services, which offer temporary care and support to families experiencing crisis situations.

Form LIC 9059 establishes procedures for handling personal property in licensed facilities in California. The form provides guidance to facility staff on how to manage residents' personal belongings, including storage, inventory, security measures, and documentation. It may cover topics such as the facility's responsibility for safeguarding personal property, procedures for returning items upon discharge or relocation, and protocols for addressing lost or damaged items.

Form LIC 9219A is used by crisis day care programs in California to document the sign-in and sign-out information of children attending the facility. This form includes fields for recording the child's name, time of arrival, time of departure, and the signature of the parent or guardian. By utilizing this sign-in form, crisis day care programs maintain accurate records of attendance, ensuring proper supervision and safety during the provision of temporary care services to children in crisis situations.

Form LIC 9222 is used to obtain parental consent and verification for blood glucose testing in child care facilities in California. This form is specifically utilized for children with diabetes or other medical conditions requiring regular blood glucose monitoring. It collects information about the child, the need for blood glucose testing, specific instructions or parameters, and parental consent for trained staff to perform the tests.

Form LIC 9221 is used in child care facilities in California to obtain parental consent for the administration of medications to children while in their care. The form collects information about the child, the medication to be administered, dosages, frequency, and any specific instructions. Additionally, it includes a medication chart that allows caregivers to record each instance of medication administration, including the date, time, medication name, dosage, and initials of the administering staff.