California Department of Social Services

Form LIC 12 is used in the context of resource family approval. It serves as an alternative plan document that outlines specific arrangements or modifications to be implemented in the resource family home to meet the requirements for approval. The form details any necessary adjustments, improvements, or alternative measures in areas such as safety, space requirements, health considerations, or other aspects identified during the assessment process.

Form LIC 300C is used to confirm the rescission of a previous removal confirmation issued for a child in a licensed facility. The form is completed by the California Department of Social Services (CDSS) to officially notify the licensee or facility operator that the previous removal confirmation has been rescinded. By utilizing this form, the CDSS informs the licensee that the previously approved removal has been canceled or reversed, providing clarity and updated information regarding the child's status in the facility.

Form LIC 603 is used to gather preplacement appraisal information for individuals considering placement in a licensed facility in California. The form is completed by the individual or their authorized representative and includes personal details, medical history, social background, and other relevant information. By utilizing this form, facility operators collect essential information to assess the individual's needs, ensure appropriate placement, and tailor their care services accordingly.

Form LIC 421BG is a specific civil penalty assessment form related to caregiver background checks in licensed facilities in California. The form is completed by the California Department of Social Services (CDSS) to inform the facility operator or licensee about the assessed civil penalty for non-compliance with caregiver background check requirements. It includes details of the violation(s), the amount of the penalty, and instructions for payment.

Form LIC 421A is used for the assessment of civil penalties against licensed facilities in California. The form is completed by the California Department of Social Services (CDSS) to notify the facility operator or licensee of the assessed civil penalty, including the violation(s) committed, the amount of the penalty, and instructions for making the payment. By utilizing this form, the CDSS communicates the penalty assessment and ensures that facilities are held accountable for non-compliance with regulatory requirements.

Form LIC 602A is a physician's report used specifically for Residential Care Facilities for the Elderly (RCFE) in California. The form is completed by a licensed physician and provides detailed information about the health conditions and medical needs of individuals residing or seeking admission to an RCFE. It includes assessments of physical and mental health, medication administration requirements, specialized treatments, and any specific recommendations for care.

Form LIC 508D is a combined form used for both out-of-state disclosures and criminal record statements in licensed facilities in California. The form is completed by individuals seeking employment or serving in positions where background checks are required, providing information on criminal history, prior convictions, and disclosure of out-of-state criminal records. By utilizing this form, facility operators gather comprehensive background information, ensuring compliance with regulations, and promoting the safety and well-being of individuals served by the facility.

Form LIC 508A is a criminal record statement used by adoption facilitators in California. The form is completed by the adoption facilitator and includes questions related to criminal history, convictions, and any relevant legal issues. By utilizing this form, adoption facilitators provide necessary information for background checks, ensuring compliance with regulations and promoting the safety and well-being of adoptive families and children involved in the adoption process.

Form LIC 507 is a work schedule form that records the staffing schedule for facilities in California. The form includes details such as staff names, assigned shifts, days off, and any additional notes or adjustments to the schedule. By utilizing this form, facility operators maintain an organized and comprehensive record of staff schedules, ensuring appropriate coverage, effective staffing management, and compliance with licensing regulations.

Form LIC 200 is an application form used by individuals or organizations seeking a license to operate a community care facility or residential care facility for the elderly in California. The comprehensive form collects detailed information about the applicant, including personal details, proposed facility location, staffing plans, program descriptions, and other pertinent information required for licensing.