California Department of Social Services

Form LIC 9102TA serves as a tool for providing technical assistance and guidance to licensed facilities in California. The form contains advisory notes, recommendations, or best practices related to various aspects of facility operations, such as health and safety, program development, staff training, documentation, or regulatory compliance. By utilizing this form, the California Department of Social Services offers resources and support to facilities, promotes continuous improvement, and facilitates adherence to licensing standards.

Form LIC 9031 is used to notify licensed facilities in California of a temporary suspension order affecting their license. The form is completed by the licensing agency and includes details such as the facility's name, address, the reason for the suspension, effective dates, and any specific conditions or requirements during the temporary suspension period. By utilizing this form, facilities receive official notification of the suspension order, allowing them to take appropriate actions, comply with regulatory directives, and seek remedies as necessary.

Form LIC 9119 is an inspection checklist specific to group homes in California. The form provides a detailed checklist of items to be evaluated during facility inspections, including areas such as resident care, staff qualifications, physical environment, medication management, record-keeping, safety protocols, and overall compliance with licensing regulations. Inspectors utilize this form to conduct thorough assessments, identify any deficiencies or violations, and support the improvement of services provided in group homes.

Form LIC 9029B is a preparation checklist used in the creation of a statement of facts regarding incidents, complaints, or investigations in licensed facilities in California. The form is completed by authorized personnel involved in the preparation process and provides a structured guide to ensure all relevant information is included in the statement. It covers areas such as incident descriptions, involved parties, dates and times, witness statements, supporting documentation, and any required attachments.

Form LIC 9122A is an inspection checklist specifically designed for small family homes in California. The form provides a comprehensive list of items to be evaluated during facility inspections, including areas such as resident care, staffing, safety measures, health services, medication management, record-keeping, and compliance with licensing regulations. Inspectors utilize this form to assess compliance with licensing requirements, identify any deficiencies or areas needing improvement, and support the provision of quality care in small family homes.

Form LIC 9121 is a facility visit checklist specifically designed for family child care providers in California. The form provides a detailed checklist of items to be assessed during facility visits, including areas such as health and safety practices, supervision protocols, program activities, nutrition and mealtime routines, record-keeping, and compliance with licensing regulations.

Form LIC 9120A is a licensed facility inspection checklist specifically designed for adult care facilities in California. The form provides a comprehensive list of items to be evaluated during facility inspections, including areas such as resident care, staff qualifications, safety measures, health services, medication management, record-keeping, and compliance with licensing regulations. Inspectors utilize this form to assess compliance with licensing requirements, identify any deficiencies or areas needing improvement, and support the provision of quality care in adult care facilities.

Form LIC 9054 provides information about the local fire inspection authority to licensed facilities in California. The form includes details such as the contact information for the local fire department or fire marshal's office responsible for conducting fire inspections and enforcing fire safety regulations. It may also outline specific requirements or procedures related to fire inspections, fire drills, emergency evacuation plans, and necessary fire safety equipment.

Form LIC 989A is used to request non-confidential records from licensed facilities in California. The form is completed by individuals or organizations seeking access to specific records that are not confidential or protected by privacy laws. It includes details such as the requester's name, contact information, the purpose of the request, and the specific records being sought. By utilizing this form, licensed facilities can process non-confidential records requests efficiently, ensure compliance with disclosure requirements, and safeguard the confidentiality of sensitive information.

Form LIC 858 is used to conduct a review of client or resident records in licensed facilities in California. The form is completed by authorized personnel, such as licensing agency staff or auditors, and involves a thorough examination of the records maintained for clients or residents in the facility. It assesses documentation related to assessments, care plans, medical records, medications, incident reports, progress notes, and other relevant information.