(November 10, 2022), The fingerprint form is now generated through the provider's Child Care Licensing Portal. Certification of School Building Fire Safety Provisions CCL-5043 - Word, Self-Certification of Transportation Provisions for Centers CCL-5044 - PDF Salt Lake City, UT 84116, Headquarters Step 2: Once you have entered the editing page lic 500 community care licensing, you will be able to notice every one of the options available for your file at the upper menu. Licensed Provider Resources. [opens in a new window] Referral Form for Clinical Trials. Not the right email? Digital signatures are secured against your email so it is important to verify your email address. To enter and activate the submenu links, hit the down arrow. Although all of the information is the same, there may be some confusion about where to find everything on our newly designed CCL Website. English. 195 North 1950 West CareWeb Provider Connection Security Request Form. However, if you provide CDSS with any type of contact information, this allows you to receive further information from the local licensing office about the status of this complaint. Designation Of Administrative Responsibility (Lic 308), Affidavit Regarding Client Cash Resources (Lic 400), Supplemental Financial Information (Lic 401a), Balance Sheet Supplemental Schedule (Lic 403a), Financial Information Release & Verification (Lic404). Small Family Homes. Attention A T users. View our employee call list. Let Us No to submit a complaint. Human Services License. Submit a written report of the special incident to the regional center within 48 hours (calendar days) of the occurrence of the special incident. You can pay fees here with a Visa, MasterCard, or with your debit card, if it has a Visa or MasterCard Logo. (July, 2022), Licenses, Certificates, Approvals, & Exemptions, Abuse/Neglect of Seniors and Adults with Disabilities. We received a lot of applications for the 2022 Compliance Grant and hope to have notifications out by the end of September. Select option 1 for Claims and Eligibility. YP, the YP logo and all other YP marks contained herein are trademarks of YP LLC and/or YP affiliated companies. Annual License Fee Notice - County - LIC 201F. Criminal Record Exemption Process - (including information regarding live scan). GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING Instructions for the LIC 9163 1. . 1-800-371-7897 Home > School Year Summer Fun FORMS Newsletter Gallery Community Care Licensing Forms . The Office of Background Processing staff will wait 20 working days and, if they don't receive fingerprints within that time, they will cancel the background check form. Listed below are the required forms to be completed by every child care facility owner and employee (age 18 and older) for the required background check per NRS 432A.175. For more information regarding the complaint process, please see Provider Information Notice (PIN) LIC 624, Unusual Incident/Injury Report. 1-800-273-TALK(8255) If you hire Mitchell & Mitchell to do your program design and corrections for Regional, the cost is $3,000.00. LIC 700. The PDF versions are not fillable and are intended for printing. This manual is used to interpret and apply regulations The CCLD site provides links to other sites of interest including provider associations and state agencies. }else{ Unless you specifically request otherwise, neither the substance of the complaint provided to the licensee, Use Fill to complete blank online CALIFORNIA pdf forms for free. 1. Crisis Line & Mobile Outreach Team Mitchell & Mitchell - Community Care Program Design Consultants. Claim for Payment of Cost of Unauthorized Medical Services, VA Form 10-583 (Fillable PDF) Claim for Miscellaneous Expenses. Licensing Forms - Licensing Forms generally begin with "LIC". 1-801-587-3000 When fingerprints are required for the covered individual, the person who authorized the background check form is to click that button, print the downloaded form, and give the form to the individual to hand to the technician capturing their fingerprints. Application for Child Care Plan Review (BCHS-FS-13), Child Care Center Notice of Arraignment or Conviction CCL-1486 - PDF, Child Care Center Notice of Arraignment or Conviction CCL-1486 - Word, Child Information Record - CCL-3731 Web Proected, Child Information Record - BCAL 3731-AR (Arabic), Documento de Informacin del Nio Estado de Michigan - BCAL-3731-SP, Written Information Packet Documentation CCL-4340 - PDF, Written Information Packet Documentation CCL-4340 - Word, Change of Use Space Request for School-Age Programs Located in Schools CCL-4342 - PDF, Change of Use Space Request for School-Age Programs Located in Schools CCL-4342 - Word, Lead Hazard Risk Assessment Summary CCL-4344 - PDF, Lead Hazard Risk Assessment Summary CCL-4344 - Word, No Change in Building Construction Declaration CCL-2129 - PDF, No Change in Building Construction Declaration CCL-2129 - Word, Infant/Toddler Primary Caregiver Documentation CCL-4557 - PDF, Infant/Toddler Primary Caregiver Documentation CCL-4557 - Word, Center Fire and Tornado Drill Record - CCL-4593 - PDF, Center Fire and Tornado Drill Record - CCL-4593 - Word, Staffing Plan: Child Care Center CCL-5001 - PDF Michigan Office of Administrative Hearings and Rules. You can use the sample forms as they are or change them to meet your needs. Please switch auto forms mode to off. Fingerprinting Instructions; Background Check Consent and Release; List of Disqualifying Crimes Our mailing address is: Office of Licensing Residential Care Facilities for the Elderly. The Live Scan Operator will complete section 8. CCL Mission: To support the child care community by protecting the health and safety of children in child care programs we oversee. 2. Crisis Line & Mobile Outreach Team Complete this form within 72 hours of calling in a suspicion of abuse or neglect. Please call with any questions or to connect with a Licensing staff member. I can cook,clean,and anything else needed. YP - The Real Yellow PagesSM - helps you find the right local businesses to meet your specific needs. Child Abuse/Neglect The Word documents are fillable and are intended for electronic completion. Our analysts can investigate your complaint more thoroughly when sufficient details are provided. The Community Care Licensing (California) form is 1 page long and contains: Fill has a huge library of thousands of forms all set up to be filled in easily and signed. The CCL website contains regularly updated information on various topics. Send to someone else to fill in and sign. National Suicide Prevention Lifeline Tome un minuto para ver una presentacin de nuestro sitio web haciendo clic aqu: As the result of a federal audit and to ensure the consistency of inspections, licensors are assessing compliance with all rules and requirements at all inspections. Select option 2 for Provider Management. Regional Offices Contact Information. Listed below are the required forms to be completed by every child care facility owner and employee (age 18 and older) for the required background check per NRS 432A.175. Once finished you can manually add any additional fields and signatures to the document by dragging them from the toolbar. Default; Distance; Rating; Name (A - Z) Sponsored Links. Fillable Portable Document Formats can be completed online, edited, saved and printed. However, if you provide CDSS with any type of contact information, Application (Lic 200) Applicant Information (Lic 215) Designation Of Administrative Responsibility (Lic 308) Administrative Organization (Lic 309) Affidavit Regarding Client Cash Resources (Lic 400) Surety Bond (Lic 402) Monthly Operating Statement (Lic 401) See our locations servicing Fresno, Merced, Tulare/Kings, Madera, and Mariposa Counties. LIC 702. Application for a Child Care Center License - LIC 200A. } For every single segment, fill out the content requested by the software. From Business: I babysit I love kids you will be in good care when i take care of your kids I am the oldest of 33 grandchildren. Community Care Licensing Forms. (January 30, 2023), Take a minute to watch a tour of the website by clicking here: Childcarelicensing.utah.gov, Tome un minuto para ver una presentacin de nuestro sitio web haciendo clic aqu: Childcarelicensing.utah.gov. Playground Inspection Certification Summary CCL-5047 Word, Incident Report CCL-4605 - PDF Office of Accountability & Whistleblower Protection, Training - Exposure - Experience (TEE) Tournament, Indian Health Service/Tribal Health Program, CHAMPVA In-house Treatment Initiative (CITI), Training Courses and Educational Resources, Indian Health Services/Tribal Health/Urban Indian, Spina Bifida Health Care Benefits Program, Veterans Health Information Exchange Program, Durable Medical Equipment/ Pharmacy Requirements, War Related Illness & Injury Study Center, Clinical Trainees (Academic Affiliations), Call TTY if you We do have staff monitoring the incoming mail on a daily basis in the event that electronic submission is unavailable to you. Caring for Mi Future is a $100 million strategy to open 1,000 new child care programs by the end of 2024. We recommend emailing all submissions to our office via the following means: Submit a concern or critical incident regarding a program or provider, (801) 538-4242 Preferred listings, or those with featured website buttons, indicate YP advertisers who directly provide information about their businesses to help consumers make more informed buying decisions. Welcome to the Community Care Licensing Division. If you continue to use your current browser then Fill may not function as expected. An Online Resource for Skilled Immigrants. LIC 624, Unusual Incident/Injury Report (PDF; 78.21 KB) LIC 624 (SP), Reporte de incidente inusual o lesin (pdf; 80.58 KB) Multi-Agency State Office Building 1-801-587-3000 if(responsiveVoice.isPlaying()){ | A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z |, Admission Agreement For Residential Care Facilities For The Elderly LIC 604A, Admission Agreement Guide For Residential Facilities LIC 604, Affidavit Regarding Client/Resident Cash Resources LIC 400, Affidavit Regarding Liability Insurance For Family Child Care Home LIC 282, Annual License Fee Notice County LIC 201F, Applicant Fingerprint Follow-Up Request LIC 107, Application for a Child Care Center License LIC 200A, Application For A Community Care Facility or Residential Care Facility For The Elderly License LIC 200, Application For A Family Child Care Home License LIC 279, Application Instructions for A Facility License LIC 281, Appraisal/Needs And Services Plan LIC 625, Balance Sheet Supplemental Schedule LIC 403A, Centrally Stored Medication And Destruction Record LIC 622, Certificate Of Approval (For Certified Family Homes) LIC 229, Child Abuse Central Index Check For County Licensed Facilities -LIC 198, Child Abuse Central Index Check For State Licensed Facilities LIC 198A, Childs Preadmission Health History Parents Report LIC 702, Civil Penalty Assessment Immediate LIC 421B, Civil Penalty Assessment (Unlicensed Facility) LIC 421A, Civil Penalty Ledger Payment, Reduction, Or Waiver Record LIC 422A, Client/Resident Personal Property And Valuables LIC 621, Confidential Report Not Subject To Public Disclosure Report Of Suspected Dependent Adult/Elder Abuse SOC 341, Consent For Emergency Medical Treatment Child Care Centers Or Family Child Care Homes LIC 627, Consent For Emergency Medical Treatment Childrens Residential Facilities LIC 627B, Consent For Emergency Medical Treatment Adult And Elderly Residential Facilities LIC 627C, Consent To A Medical Examination LIC 627A, Criminal Background Clearance Transfer Request LIC 9182, Criminal Record Statement Adoption Facilitator LIC 508A, Criminal Record Statement Long-Term Ombudsman Program LIC 508B, Current Children In Your Home Application For A Family Child Care Home License LIC 279B, Designation Of Facility Responsibility LIC 308, Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities LIC 610D, Emergency Disaster Plan For Child Care Centers LIC 610, Emergency Disaster Plan For Childrens Residential Facilities (Except Foster Family Homes) LIC 610C, Emergency Disaster Plan For Family Child Care Homes LIC 610A, Emergency Disaster Plan For Residential Care Facilities For The Elderly LIC 610E, Emergency Plan For Foster Family Homes LIC 610B, Financial Information Release And Verification LIC 404, Forms/Records To Keep In Your Family Child Care Home LIC 311D, Foster Family Home Application Instructions LIC 283A, Gastrostomy Tube Care: Physicians Checklist (Child Care Facilities) LIC 701A, Gastrostomy Tube Care Consent/Verification (Child Care Facilities) LIC 701B, Health Screening Report Facility Personnel LIC 503, Identification And Emergency Information LIC 601, Identification And Emergency Information Child Care Centers/Family Child Care Homes LIC 700, License Application And Instructions For Child Care Centers LIC 281A, License Application And Instructions For Family Child Care Homes LIC 279A, Notice Of Operation In Violation Of Law LIC 195, Notice Of Operation In Violation Of Law Family Child Care Home LIC 195A, Notification Of Incomplete Application LIC 184, Notification Of Incomplete Foster Family Home Application LIC 184A, Notification Of Initial Application Denial LIC 192, Orientation Meeting Family Child Care Home LIC 186A, Out-Of-State Child Abuse/Neglect Report Request LIC 198B, Out-Of-State Disclosure And Criminal Record Statement LIC 508D, Personal Rights Child Care Centers LIC 613A, Personal Rights Childrens Residential Facilities LIC 613B, Personal Rights Adult Residential Care Facilities LIC 613, Personal Rights Residential Care Facilities for The Elderly (Publicly Operated) LIC 613C, Personal Rights Residential Care Facilities for The Elderly (Privately Operated) LIC 613C-2, Physicians Report Child Care Centers LIC 701, Physicians Report For Community Care Facilities LIC 602, Physicians Report For Residential Care Facilities For The Elderly (RCFE) LIC 602A, Pre-placement Appraisal Information LIC 603, Record Of Clients Cash Resources For Change Of Licensee LIC 424, Record Of Clients/Residents Safeguarded Cash Resources LIC 405, Records To Be Maintained At The Facility Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children LIC 311A, Records To Be Maintained At The Facility Adult Residential LIC 311C, Records To Be Maintained At The Facility Small Family Home And Foster Family Home LIC 311E, Records To Be Maintained At The Facility Residential Care Facility For The Elderly LIC 311F, Records To Be Maintained By The Facility Group Homes LIC 311B, Reference Request Adoption Facilitator LIC 301A, Reference Request Long-Term Care Ombudsman Program LIC 301B, Release Of Client/Resident Medical Information LIC 605A, Removal Confirmation Exemption Needed LIC 300A, Removal Confirmation Non-Exemptible LIC 300D, Removal Confirmation Rescinded LIC 300C, Reporting Requirements By Licensees To The State Department Of Social Services LIC 306, Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders SOC 341a, Supplemental Financial Information LIC 401A, Unusual Incident/Injury Report Family Child Care Home LIC 624B, Your Right To Make Decisions About Medical Treatment PUB 325, If you don't see what you're looking for, please give us a call at 530-894-2114. Required for new building/renovations only. Call: 988 (Press 1), U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420. Use the links below to download these popular forms. For questions about this webpage, please call 1-844-538-8766 or email letusno@dss.ca.gov . 2021 January-June Statewide Nevada Child Care Licensing Report; Forms - Background. General Provisions - BCAL-1888, Child Care Center Compliance Record, Part 2. Programs are required to keep written The Application for Certificate of Compliance (HS 633) is used to apply for a license of the following human service programs: 1-800-897-LINK(5465), How to Submit Background Check Forms and Fingerprints, Background Check Requests From Other States. Child Care Community Organizations Human Services Organizations. Website (801) 669-5370. LARA is proud to be recognized as a Veteran-Friendly Employer committed to military veteran recruitment, training and retention practices. 19-01-CCLD Communication with Complainants FAQs(opens in new tab), If you do not know the address of the facility please use this look up feature: Forms on this site are available in several formats. What I recommend to all of my clients is this: when we get a facility number assigned to the facility, submit a program design to Regional Center, this way both program designs will be going through the vetting process at the same time, and hopefully cross the finish line around the same time. A physical address must be provided to investigate your concerns. We serve the most vulnerable people of California and our mission is to promote the health, safety, and quality of life of each person in community care through the administration of an effective and collaborative regulatory enforcement system. : DIRECT DEPOSIT CALIFORNIA To (California), FACILITY SKETCH (Floor Plan) - Family Child Care (California), UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) (California), State of California Department of Insurance Live Scan (California), WG-012 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California), Retirement Allowance Estimate Request (California), ATTACHMENT TO PROOF OF ELECTRONIC SERVICE (PERSONS SERVED) (California), Form 2: FW-002 Request to Waive Additional Court (California), POS-050/EFS-050 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California), form to sign prior to submittal. 2. About Search Results. released, or otherwise made publicly available shall disclose your name as a complainant. Then mail the document to the appropriate Office of Child Care Regional Licensing Office. However, most Office of Licensing staff have transitioned to telework and are not physically present in the building. Department of Human Services > For Providers > Clearances and Licensing > App for License. The required forms are part of rule and cannot be changed. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links. We additionally have phone coverage during weekday business hours at 801-538-4242. NOTE: Only use this form for one time release of information. If you do not have or did not receive a current . Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. Sexual Violence Crisis Line Salt Lake City, Ut 84116, DLBC Contact Info 3. Search results are sorted by a combination of factors to give you a set of choices in response to your search criteria. To date, the governor has expanded access to free or low cost child care for 150,000 more kids . Cancel at any time. The Word documents are fillable and are intended for electronic completion. You're on your way to completing your first doc! A "Download Fingerprint Form" button will appear after a background check form is authorized. You will need to contact your local licensing office for all other clearance verifications. The web Browser you are currently using is unsupported, and some features of this site may not work as intended. You will need to contact the local licensing office for dates and times the administrator exam is given. They may be used as posted here or you can create your own versions. 1-888-421-1100 resident, or child and their location, such as their room number, classroom, unit, or wing number. Please update to a modern browser such as Chrome, Firefox or Edge to experience all features Michigan.gov has to offer. Child Care Licensing Program Office 744 P Street, MS: T9-15-48 Sacramento, CA 95814 Phone (916) 651-6040 Fax (916) 651-0531 Northern Regional Offices Assistant Program Administrator, Robert Garza (916) 651-6040, Alt. To promote this requirement at your child care center or family care home, you may distribute copies of this flyer (also in Spanish) (PDF). LIC 613A. I looked for a long time for a daycare where I knew my son would be loved and cared, Im super satisfied with this childcare! FAMILY CHILD CARE HOME ADDENDUM TO NOTIFICATION OF (California), EARTHQUAKE PREPAREDNESS CHECKLIST (EPC) * (California), FAMILY CHILD CARE HOME OTIFICATION OF PARENTS RIGHTS (California), EMERGENCY DISASTER PLAN FOR FAMILY CHILD CARE HOMES (California), ADVANCE HEALTH CARE DIRECTIVE FORM (California), FORM MUST BE SIGNED. Complete our forms to check eligibility, report incidents, or assessment worksheets, Our counselors and staff can help you with your requests or concerns. Big Brothers Big Sisters. LIC 627. This is accomplished by: Establishing, monitoring, and assessing health and safety standards; Salt Lake City, UT 84116. Your identity as a complainant is confidential. Report Fraud & Abuse. This is to verify the identity of the covered individual and to ensure all covered individuals passed the background check. The Inspection Checklists are the ones used by licensors . Publicly posted details related to Operations in Contravention of the Community Care and Assisted Living Act are current and available. Please include names, dates, witnesses, others who have knowledge of the concern, and any other relevant information. IMPORTANT: You must have Adobe Reader version 6.0 or later installed on your computer to view the documents on this site. If you do not have Adobe Reader, you can download this FREE software from the Adobe website. the application book is "LIC 281" Community Care Updates - Quarterly updates on items of interest and program changes you need to know about. Hit enter to expand a main menu option (Health, Benefits, etc). 1-800-371-7897 You may (California), Regional Early Action Planning Grant Application (REAP) (California), RI-FL020 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State (California), RECERTIFICATION FOR CALFRESH BENEFITS (California), VENDOR APPLICATION DS 1890 (Rev. Headquarters Remember to include the who, what, when, where, and how regarding the incident. Next print the form and then fill in the required responses. 1-855-323-DCFS(3237) Providers will then have to submit another background check form and fingerprints if they still want the covered individual's background check to be processed. Completing the transition to our new database is a priority. This is one piece of a historic $1.4 billion investment to expand access to quality, affordable child care for families. LARA is dedicated to bridging the gap between civilian and military employment and helping veterans gain and retain employment. Application Process: Call or visit website for additional information. Milwaukee: 1-414-902-237 5. This report provides a glimpse of child care numbers crossing jurisdictional lines by giving total number of licensed facilities, number of each type of facility licensed, number of substantiated and unsubstantiated complaints and more throughout Nevada. Provo, UT 84604. You have successfully completed this document. Please visit the VA Forms page for other forms not listed here or to search for a specific VA form. Access the California Department of Social Services Community Care Licensing Division website at www.ccld.ca.gov. Facility Search Tool (opens in new tab). Contact Us, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities Family and Group Home Increased Capacity and Ratio Request - Word Version, Family and Group Home Increased Capacity and Ratio Request PDF Version, Waiver for Decreasing Capacity Fillable Word Version, Waiver for Decreasing Capacity PDF Version, Request of Child Care Forms CCL-2021 PDF, Request of Child Care Forms CCL-2021 Word, Child Care Licensing Information Request - CCL 001 -PDF, Child Care Licensing Information Request - CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - PDF, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word, Background Check and Fingerprinting Information, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - PDF, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - Word, Medical Clearance Request - CCL-3704 - PDF, Medical Clearance Request - CCL-3704 - Word, Child Information Record - CCL-3731 - PDF, Child Information Record - CCL-3731 - Word, Child Information Record - CCL 3731-AR (Arabic), Documento de Informacin del Nio Estado de Michigan - CCL-3731-SP, Zoning Approval for Group Child Care Homes - CCL-3748 - PDF, Zoning Approval for Group Child Care Homes - CCL-3748 - Word, Declaracin/Recibo de Nios en Cuidado - CCL-3900-SP, Child in Care Statement/Receipt - CCL-3900 - PDF, Child in Care Statement/Receipt - CCL-3900 - Word, Training Record Family/Group Child Care Homes - CCL-4590 PDF, Training Record Family/Group Child Care Homes - CCL-4590 - Word, Assistant Caregiver Certifications - CCL-4595 - PDF, Assistant Caregiver Certifications - CCL-4595 - Word, Home Fire and Tornado Drill Record - CCL-4593 - PDF, Home Fire and Tornado Drill Record - CCL - 4593 - Word, Licensing Notebook Summary Sheet - CCL-5052 - PDF, Licensing Notebook Summary Sheet - CCL-5052 - Word, Request for Modification of the Terms of the License - CCL-5054 - PDF, Request for Modification of the Terms of the License - CCL-5054 - Word, Variance Request Early Childhood Program Director Fillable Word Version, Variance Request Early Childhood Program Director PDF Version, Variance Request School-Age Program Director Fillable Word Version, Variance Request School-Age Program Director PDF Version, Variance Request Lead Caregiver Fillable Word Version, Variance Request Lead Caregiver PDF Version, Child Care Licensing Information Request - BCHS-CCL 001 - PDF, Child Care Licensing Information Request - BCHS-CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word. 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Are or change them to meet your needs modern browser such as Chrome, Firefox or Edge to experience features! Free software from the toolbar passed the background check Firefox or Edge to experience all features Michigan.gov has offer!
