Form LIC 855 is a declaration form used in licensed facilities in California. The form is completed by individuals involved in incidents, complaints, or investigations and provides a sworn statement or declaration regarding their knowledge, observations, or experiences related to the matter under review. It includes details such as the individual's name, contact information, and a narrative account of the circumstances.
Form LIC 610A is an emergency disaster plan specific to family child care homes in California. The form is completed by the home operator and outlines procedures and protocols to address potential emergencies or disasters, such as natural disasters, fires, or medical emergencies. It includes information about evacuation plans, emergency contacts, communication strategies, and necessary supplies.
Form LIC 812 is used to provide additional detailed information related to specific incidents, complaints, or investigations in licensed facilities in California. The form is completed by facility staff or authorized personnel and includes supplemental documentation, reports, witness statements, photographs, or any other relevant information that supports the understanding and resolution of the matter at hand.
Form LIC 9165 is used by care facilities in California to provide a statement detailing the members of their board of directors. This form includes information such as the names, addresses, and contact details of each board member. By submitting this form, care facilities comply with reporting requirements and provide transparency regarding the individuals responsible for overseeing the operations and decision-making processes within the organization.
Form LIC 9163B is used to request Live Scan services for individuals involved in Long Term Care Ombudsman programs in California. This form is completed by the applicant and submitted to authorized Live Scan service providers, who capture the applicant's fingerprints electronically. The fingerprints are then used for criminal background checks conducted by the Department of Justice and the Federal Bureau of Investigation.
Form LIC 9158 is used by care facilities in California to notify the Department of Social Services about the presence of a telecommunications device within the facility. This form is typically utilized in residential care facilities where residents are equipped with personal emergency response systems or other types of telecommunication devices. By submitting this form, care facilities comply with reporting requirements and ensure that emergency communication systems are appropriately documented, monitored, and maintained to support the safety and well-being of residents.
Form LIC 9163 is used to request Live Scan services for individuals seeking employment or volunteer positions in community care licensing programs in California. This form is completed by the applicant and submitted to authorized Live Scan service providers, who capture the applicant's fingerprints electronically. The fingerprints are then used for criminal background checks conducted by the Department of Justice and the Federal Bureau of Investigation.
Form LIC 9119CCH is an inspection checklist specific to community crisis homes (CCHs) in California. The form provides a comprehensive list of items to be evaluated during facility inspections, including areas such as resident care, crisis intervention procedures, staff qualifications, safety measures, medication management, documentation practices, and compliance with licensing regulations. Inspectors utilize this form to assess CCH operations, ensure effective crisis intervention services, and promote the well-being and safety of residents.
Form LIC 9106A is specific to short-term residential therapeutic programs (STRTPs) in California. The form provides instructions for completing the program statement required for STRTP licensure. It guides facility operators in providing essential information about their program, including therapeutic approaches, treatment modalities, staff qualifications, admission and discharge criteria, and other pertinent details.
Form LIC 9106 provides general instructions for completing the program statement required for group homes in California. The form outlines the information and components that should be included in the program statement, such as the facility's mission, goals, program services, staffing qualifications, treatment philosophies, and admission criteria. It guides facility operators in documenting the essential aspects of their group home program to ensure clarity, consistency, and compliance with licensing requirements.