Unusual incident reports, thanks to their nature, are filed by phone and in writing. COMMUNITY CARE LICENSING . LIC 9163 (12/15) - Request Live Scan Service - Community Care Licensing LIC 9163B (7/11) - Request For Live Scan Service - Long Term Care Ombudsman LIC 9165 (2/99) - Board Of Director Statement PERSON(S) WHO OBSERVED THE INCIDENT/INJURY: EXPLAIN WHAT IMMEDIATE ACTION WAS TAKEN (INCLUDE PERSONS CONTACTED): ACTION TAKEN OR PLANNED (BY WHOM AND ANTICIPATED RESULTS: AGENCIES/INDIVIDUALS NOTIFIED (SPECIFY NAME AND TELEPHONE NUMBER), LICENSING______________________________________, ADULT/CHILD PROTECTIVE SERVICES________________________, LONG TERM CARE OMBUDSMAN___________________, PARENT/GUARDIAN/CONSERVATOR__________________________, LAW ENFORCEMENT_____________________________, PLACEMENT AGENCY______________________________________, TemplateRoller. ORI: A0448 CA Dept of Social Services PO BOX 944243 Sacramento, CA 94244-2430 LIC 9163 (10/15) PAGE 1 OF 4 3. Post next to phone. Community Care Licensing Division Welcome to the Community Care Licensing Division. cna nac#7050. Welcome to your online resource for Community Care Licensing regulations and requirements. 2. Personnel changes reports are made within 10 days of the change. Download the document to your desktop, tablet or smartphone to be able to print it out in full. Video instructions and help with filling out and completing lic 624. CCHP is a program of the University of California San Francisco School of Nursing, Department of Family Health Care Nursing. Pressing the PRINT button will only print the current page. This health appraisal ... LIC 503 (ENG/SP) (3/99) PERSONAL. Family Child Care is non-medical care and supervision forchildren, in the provider’s own home, for periods less than 24 hours. retain copy of report in client’s file. Google Translate. community care licensing division . COMMUNITY CARE LICENSING DIVISION CRIMINAL RECORD STATEMENT State law requires that persons associated with licensed facilities or Home Care Aide Registry applicants be fingerprinted ... LIC 508 (7/15) REQUIRED FORM -- NO CHANGE PERMITTED PAGE 2 OF 2. Community Care Licensing Representative 2: ... [Licensing form LIC 311D appears—“Forms and Records to Keep in Your Family Child Care Home.”] And after a child leaves your care, the signed portion of the notification of parents’ rights must be kept on file for 3 years. cdss vendor: arf #2000079-735-2. brn #cep16081. telephone number ( ) address 0 nasw #886756920. rcfe #2000079-740-2. strtp #2000079-733-2. rcfe ictp #2000079-740-1 Easily fill out PDF blank, edit, and sign them. This app includes all the detailed information necessary to complete form LIC 624. 15. gh#2000079-730-2. This 1-hour course topic covers the general licensing requirements in completing a LIC 624 in residential facilities for both Adult Residential Facility and Residential Care Facility for the Elderly. 469 California Legal Forms And Templates are collected for any of your needs. %%EOF Authorized Applicant Type - Enter from list on Page 2, “DOJ Abbreviated CCLD Facility Type.” 03502 ( ) See reviews, photos, directions, phone numbers and more for State Of California Community Care Licensing locations in Fresno, CA. instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. The phone reports are made no later than the next working day after the event occurs. Licensing Forms. retain copy of report in client’s file. Learn more about how family child care homes and child care centers can protect and promote children’s health and safety. LIC 624B (6/03) SEE INSTRUCTIONS ON REVERSE 16. endstream endobj startxref EMERGENCIES - LIFE THREATENING - Call 9-1-1 - Tell them: Number Calling from: 5. Unusual incidents (LIC 624 for child care centers and LIC 624B for family child care homes) is one type of such reports. State Child Care Licensing County Child Care Licensing Child Protective Services Law Enforcement. Download our form. One type is unusual incidents. CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT . REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING Applicant Submission 1. Community Care Licensing Representative 2: On the Licensing website you’ll find emergency disaster planning forms that must be completed as part of your license application. PARENT’S SIGNATURE . Form LIC 624, Unusual Incident/Injury Report, also known as the LIC injury report form or the LIC unusual incident report form, is an application created for daycare providers that allows them to report unusual incidents and/or injuries to the appropriate California state agencies. TemplateRoller.com will not be liable for loss or damage of any kind incurred as a result of using the information provided on the site. These reports are mandatory for both family child care homes and centers. Outbreaks of communicable diseases (e.g. Enter the current month, day, and year. By the end of this course, participant will: Identify the proper documentation to use in filling out an incident report in a residential facility. name of facility . submit written report within 7 days of occurrence. This website includes videos that explain licensing topics relevant to families and licensed child care providers. LICENSEE NAME: 1. 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