California Department of Social Services

Form LIC 420 is used to provide budget information for licensed facilities in California. The form is completed by the facility operator or licensee and includes details of projected income and expenses, anticipated cash flow, and other financial aspects related to the facility's operation. By utilizing this form, facility operators develop and present a comprehensive budget that assists in financial planning, resource allocation, and ensuring compliance with licensing requirements.

Form LIC 198B is used to request out-of-state child abuse/neglect reports for individuals applying to work or be involved in licensed facilities or programs in California. The form is submitted to the appropriate agencies or departments in other states to obtain information about any substantiated child abuse or neglect reports involving the individual. By utilizing this form, the California Department of Social Services (CDSS) ensures a comprehensive background check and helps prevent the employment or participation of individuals with a history of child abuse or neglect.

Form LIC 406 is used to document and track cash transactions related to clients or residents in licensed facilities in California. The form is completed by facility staff and captures details of cash received, disbursed, or held on behalf of clients or residents. It includes information about the purpose of the transaction, the amount involved, and relevant dates. By utilizing this form, facility operators maintain accurate records of cash transactions, enabling financial transparency and accountability in the management of client or resident funds.

Form LIC 501 is a record used to document and maintain personnel information for Community Care Licensing (CCL) purposes in licensed facilities in California. The form is completed by the facility operator or licensee and includes essential details about employees, such as their name, address, position, date of birth, educational background, work experience, and any relevant training or certifications. By utilizing this form, facility operators ensure that personnel records are complete, up-to-date, and readily available for CCL review and compliance purposes.

Form LIC 405 is used to maintain a record of safeguarded cash resources belonging to clients or residents in licensed facilities in California. The form is completed by the facility operator or designated personnel and includes details of cash resources held on behalf of clients or residents, such as deposits, withdrawals, disbursements, and account balances. By utilizing this form, facility operators ensure proper documentation and management of client or resident funds, promoting transparency, accountability, and the protection of financial resources.

Form LIC 404 is used to obtain the release and verification of financial information from individuals or entities associated with licensed facilities in California. The form is completed by the facility operator or licensee and includes authorization for the release of financial records, verification of income, assets, and other relevant financial details. By utilizing this form, facility operators gather necessary information to assess eligibility, determine financial resources, and ensure compliance with applicable regulations.

Form LIC 03 is a checklist document used by agencies involved in the assessment and approval process of resource families. It aids in evaluating the health and safety conditions of the resource family home to ensure compliance with licensing standards and regulations. The checklist covers various aspects, including structural safety, sanitation, emergency preparedness, and availability of essential facilities and equipment.

Form LIC 421FC is a civil penalty assessment form used by the California Department of Social Services (CDSS) to address repeated violations and failure to correct deficiencies in licensed facilities. The form is completed by the CDSS to inform the facility operator or licensee about the assessed civil penalty due to non-compliance with corrective actions and recurrence of violations. It includes details of the specific violation(s), the amount of the penalty, and instructions for payment.

Form LIC 403A is a supplemental schedule used in conjunction with the Balance Sheet (LIC 403) for licensed facilities in California. The form provides additional details, explanations, or breakdowns of specific balance sheet components, such as assets, liabilities, and equity. By utilizing this form, facility operators can provide further clarity and insights into their balance sheet, enabling a comprehensive understanding of the facility's financial condition and compliance with applicable regulations.

Form LIC 300B is used to confirm the denial of a request for removal or discharge of a child from 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 request for removal has been denied. By utilizing this form, the CDSS communicates the decision to deny the removal and provides reasons for the denial, ensuring transparency and accountability in the removal process.