California Department of Social Services

Form LIC 9098 is utilized to provide proof of correction for deficiencies identified during inspections or investigations in licensed facilities in California. The form is completed by the facility, indicating the specific deficiency that has been corrected, the corrective action taken, and any supporting documentation or evidence. By utilizing this form, facilities demonstrate compliance with licensing requirements, address identified deficiencies promptly, and ensure that corrections are properly documented and communicated to the licensing agency.

Form LIC 809 is used for conducting facility evaluations in licensed facilities in California. The form is completed by authorized evaluators and includes a comprehensive assessment of various aspects of the facility, including physical conditions, safety measures, staffing, programming, resident or participant rights, and compliance with licensing regulations. It may also involve interviews with staff, residents, or participants, as well as observations of daily operations.

Form LIC 808 is a comprehensive plan that outlines specific mitigation strategies for epidemic outbreaks, with a focus on addressing the COVID-19 pandemic. The form is completed by licensed facilities in California and includes details such as infection prevention protocols, employee training plans, visitor restrictions, personal protective equipment (PPE) requirements, testing strategies, and communication strategies during an outbreak.

Form LIC 9099 is used to document the findings and outcomes of complaint investigations conducted in licensed facilities in California. The form is completed by authorized personnel, such as licensing investigators, and includes information about the nature of the complaint, investigation procedures, interviews conducted, evidence gathered, and the final determination of the complaint. It may also outline any recommended corrective actions or enforcement measures.

The LIC 701 form, Physician's Report - Child Care Centers, is a document completed by a licensed physician or authorized health care professional. It provides a comprehensive overview of a child's health status, including medical history, immunization records, any diagnosed conditions, and specific health care needs. This report helps child care centers ensure the appropriate care and accommodations are in place to meet the child's medical needs while in their care.

Form LIC 9119AA is an inspection checklist specifically designed for adoption agencies in California. The form provides a comprehensive checklist of items to be evaluated during facility inspections, including areas such as adoption processes, staff qualifications, record-keeping, background checks, adoption assessments, post-placement services, and compliance with adoption-related regulations. Inspectors utilize this form to assess agency operations, ensure adherence to licensing requirements, and promote ethical and safe adoption practices.

The LIC 702 form, Child's Preadmission Health History - Parent/Authorized Representative Report, serves as a comprehensive health history questionnaire filled out by parents or authorized representatives during the enrollment process of a child in a child care center or family child care home. It requests detailed information about the child's past and current health conditions, allergies, medications, dietary requirements, and any other relevant health-related details that can help child care providers ensure the child's safety and well-being while in their care.

These instructions provide guidance on how to complete Form ICPC-100A, which is used for requesting the Interstate Compact on the Placement of Children (ICPC). The ICPC is a legal agreement between states that facilitates the placement of children across state lines for foster care, adoption, or other types of out-of-home placements. The instructions outline the necessary information and steps to be followed when filling out the form, ensuring compliance with the requirements of the ICPC.

The LIC 421D form is specifically designed by the California Department of Social Services for assessing civil penalties in cases involving death, serious bodily injury, or physical abuse. It serves as a legal instrument to document and evaluate instances where licensed facilities or individual caregivers are held accountable for causing severe bodily harm to children or adults under their supervision.

Form LIC 500 is a personnel report used by licensed facilities in California to provide information about their employees or staff members. The form is completed by the facility operator or licensee and includes details such as the employee's name, position, date of hire, qualifications, work history, and any relevant certifications or training.