California Department of Social Services

The LIC 421D form is used by the California Department of Social Services to assess civil penalties in cases involving death, serious injury, or physical abuse. This form is typically utilized when a licensed facility or individual caregiver is found responsible for incidents resulting in the death or significant harm to a child or adult under their care. The form serves as an official document to document the evidence and details surrounding the incident, including the nature of the injuries sustained and any pertinent information related to the abuse or neglect.

Form LIC 421D is a civil penalty assessment form used by the California Department of Social Services (CDSS) in cases involving death, serious bodily injury, or physical abuse in licensed facilities. The form is completed by the CDSS to notify the facility operator or licensee about the assessed civil penalty due to these grave incidents. It includes information about the specific violation(s), the amount of the penalty, and instructions for payment.

Form LIC 421CC is a civil penalty assessment form specific to child care facilities in California. The form is completed by the California Department of Social Services (CDSS) to notify the facility operator or licensee about assessed civil penalties for violations related to child care regulations. It includes information about the specific violation(s), the amount of the penalty, and payment instructions. By utilizing this form, the CDSS enforces compliance with child care standards and promotes the safety and welfare of children in licensed facilities.

Form LIC 606 is a disclosure worksheet specific to Residential Care Facilities for the Elderly (RCFE) in California. The form is completed by facility operators and serves as a checklist to ensure compliance with disclosure requirements mandated by licensing regulations. It covers various aspects of facility operations, such as staffing, services provided, physical environment, emergency preparedness, fees, and resident rights.

Form LIC 605A is a release form used to obtain consent for the release of client or resident medical information in licensed facilities in California. The form is completed by the client, resident, or their authorized representative and authorizes the facility to disclose specific medical information to designated individuals or entities. By utilizing this form, facility operators ensure compliance with privacy regulations, protect the confidentiality of medical records, and facilitate appropriate communication and coordination of care between healthcare providers and involved parties.

Form LIC 508 O-O-S (Out-Of-State Disclosure) is a standalone form used to disclose out-of-state criminal records for individuals seeking employment or serving in positions where background checks are required in licensed facilities in California. The form is completed by the applicant or employee and provides information regarding prior criminal convictions or legal issues outside of California.

Form LIC 05A is a certificate issued to individuals or families upon their approval as resource families. This certificate serves as official documentation confirming that the applicants have successfully completed the assessment, training, and approval process required to become resource families. It includes important details such as the names of the approved resource family, the date of approval, and any relevant identification or reference numbers.

Form LIC 604 is an admission agreement guide designed for residential facilities in California. The form serves as a reference and guide to assist facility operators and prospective residents or their legal representatives in understanding the terms, conditions, and rights associated with admission to a licensed facility. It provides information on services offered, fees, resident rights, discharge policies, and other important considerations.

Form LIC 421IM is a civil penalty assessment form used by the California Department of Social Services (CDSS) to address immediate and repeat violations in licensed facilities. The form is completed by the CDSS to notify the facility operator or licensee about the assessed civil penalty, which involves an immediate fine of $500 due to recurring violations. It includes information about the specific violation(s), the amount of the penalty, and instructions for payment.

Form LIC 603A is an appraisal form used to evaluate residents in licensed facilities in California. The form is completed by the facility staff and includes assessments of the resident's physical, mental, and emotional well-being, functional abilities, social engagement, and overall support needs. By utilizing this form, facility operators gather comprehensive information about each resident, enabling personalized care planning, monitoring of progress, and ensuring the provision of appropriate services based on individual needs.