Sexual Violence Crisis Line They may be used as posted here or you can create your own versions. Welcome to the Community Care Licensing Division. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. Child Care Community Organizations Human Services Organizations. General Provisions - BCAL-1888, Child Care Center Compliance Record, Part 2. If you continue to use your current browser then Fill may not function as expected. We additionally have phone coverage during weekday business hours at 801-538-4242. Email: dhslicensing@utah.gov, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities Required for new building/renovations only. Verification Of Administrator Qualifications & Certification. LIC 700. However, most Office of Licensing staff have transitioned to telework and are not physically present in the building. Claim for Miscellaneous Expenses, VA Form 10-7959e (Fillable PDF) NOTE: This form is not for provider use. Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF This document is locked as it has been sent for signing. The Word documents are fillable and are intended for electronic completion. LIC 613A. 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 Website (801) 669-5370. The required forms are part of rule and cannot be changed. (559) 243-4588 Carmen Richins, who has been serving as the Office of Background Processing Director, is now the Interim Director of the Division of Licensing & Background Checks, and Simon Bolivar is the Director of the Office of Licensing under that division. COMMUNITY CARE LICENSING DIVISION ADVOCACY AND TECHNICAL SUPPORT RESOURCE GUIDE MEDICATIONS FOR SENIOR CARE FACILITIES TSP 2016-03 (version 09/30/2016) PAGE 4 Incidental Medical and Dental Care Services (22 CCR 87465) Scenario: Description of Regulations: Best Practices: Medications required to be centrally stored, continued Application For A Family Child Care Home . During inspections, licensors will ask to see a government-issued photo ID (or a copy of that ID) for each covered individual. Hey, thats $39,564.00 a month for 4 clients, $474,768.00 a year. the application book is \"LIC 281\" Community Care Updates - Quarterly updates on items of interest and program changes you need to know about. Get started with our no-obligation trial. responsiveVoice.cancel(); (To attach multiple files, click the first file and then hold the control key down and click on any additional files.). Completing the transition to our new database is a priority. You have successfully completed this document. Licensing & Providers. If you hire Mitchell & Mitchell to do your program design and corrections for Regional, the cost is $3,000.00. YP, the YP logo and all other YP marks contained herein are trademarks of YP LLC and/or YP affiliated companies. Payment/Insurance Accepted: Please contact provider for accepted forms of payment. We are pleased to announce Child Care Licensing is now part of the newly consolidated Department of Health and Human Services (DHHS). Digital signatures are secured against your email so it is important to verify your email address. 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. All other marks contained herein are the property of their respective owners. Application for a. Primary (Consumer) Advisory Committee (PAC), Home & Community-Based Services (HCBS) Final Rule Information Page, Residential Service Provider News & Updates, Vendor (Provider) Advisory Committee (VAC). Transitional Housing Placement Program. Please include names, dates, witnesses, others who have knowledge of the concern, and any other relevant information. California Community Care Licensing (CCL) Requirements Licensed child care programs must conduct emergency drills at least once every 6 months. Provider Forms. ADA Access: Please contact facility for accessibility information. Below are forms and documents for your inspections. 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. All forms are printable and downloadable. Milwaukee: 1-414-902-237 5. 1-888-421-1100 : 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. Big Brothers Big Sisters. Fill is the easiest way to complete and sign PDF forms online. Crisis Line & Mobile Outreach Team 1-800-371-7897 This is to verify the identity of the covered individual and to ensure all covered individuals passed the background check. 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. 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) (November 10, 2022), The fingerprint form is now generated through the provider's Child Care Licensing Portal. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. [opens in a new window] IHPP Referral Form for Authorization. Publicly posted details related to Operations in Contravention of the Community Care and Assisted Living Act are current and available. To access the menus on this page please perform the following steps. Then mail the document to the appropriate Office of Child Care Regional Licensing Office. Human Services License. Providers may not make any purchases or begin any installations until the contract is fully executed. Application Process: Call or visit website for additional information. You will recieve an email notification when the document has been completed by all parties. 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. . For more information regarding the complaint process, please see Provider Information Notice (PIN) Residential Care Facilities for the Elderly. For questions about this webpage, please call 1-844-538-8766 or email letusno@dss.ca.gov . 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 contract is fully executed when both parties have signed and dated the contract.). The Community Care Licensing Division of the California Department of Social Services has provided this document search application to provide the public with access to information regarding facilities licensed by the Division. 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. Forms. Take two copies of this form with you the day you are fingerprinted. Going back to work after having my baby was really hard for me. 1-801-587-3000 Although all of the information is the same, there may be some confusion about where to find everything on our newly designed CCL Website. Let Us No to submit a complaint. WILLOW GLEN COMMUNITY EXTENDED DAY ENRICHMENT PROGRAM. Regional Center pay $9,891.00 a month for a level 4i client, but they only allow you to put one client in a bedroom. released, or otherwise made publicly available shall disclose your name as a complainant. Home > School Year Summer Fun FORMS Newsletter Gallery Community Care Licensing Forms . This form can be submitted anonymously. Mitchell & Mitchell - Community Care Program Design Consultants. 195 North 1950 West have hearing loss. CareWeb Provider Connection Security Request Form. Final decisions have not yet been made and contacting CCL staff may delay that decision making process. Begin opening a form by clicking on its name or number. Volunteer Certification for Field Trip Transportation CCL-5046 - Word, Playground Inspection Certification Summary CCL-5047 - PDF Programs are required to keep written }else{ Submit a written report of the special incident to the regional center within 48 hours (calendar days) of the occurrence of the special incident. They must be completed manually. The Word documents are fillable and are intended for electronic completion. Nevada Division of Public and Behavioral Health (DPBH), The Official State of Nevada Website | Copyright 2021 State of Nevada - All Rights Reserved, Department of Health and Human Services (DHHS), Behavioral Health Wellness and Prevention, Maternal, Child & Adolescent Health (MCAH), Public Health Informatics & Epidemiology (OPHIE), Behavioral Health and Wellness Council (BHWC), Clinical Behavioral Services (inpatient: SNAMHS, NNAMHS, Lakes Crossings), Clinical Behavioral Services (Outpatient: NNAMHS Assisted Outpatient Treatment - AOT), Substance Abuse Prevention and Treatment Agency (SAPTA), Diabetes Prevention and Control (Diabetes), Heart and Stroke Prevention and Control (Heart), Nevada Responsible Tobacco Retailer Training and Certification Program, Clinical Admin Department Business Office, Clinical Admin Department Quality Assurance/Performance Improvement, Clinical Admin Department Human Resources, Clinical Consumer Assistance Program (CAP)/Peer Support Programs, Clinical Counseling Programs Co-Occurring Programs: Dual Success & Recovery Program, Clinical Program for Assertive Community Treatment (PACT), National Health Service Corps and Nurse Corps Programs, Nevada Conrad 30/J-1 Physician Visa Waiver Program, Shortage Area Designations (HPSAs and MUA/Ps), Teen Pregnancy Prevention - Personal Responsibility Education Program (PREP), Teen Pregnancy Prevention - Abstinence Education Grant Program (AEGP), Early Hearing Detection and Intervention (EHDI), Child and Youth with Special Health Care Needs (CYSHCN), Pregancy Risk Assessment Monitoring System (PRAMS), Alliance for Innovation on Maternal Health - AIM, Public Health Informatics and Epidemiology, Adult Hepatitis and Control Program (Hepatitis), Behavioral Risk Factor Surveillance System (BRFSS), Epidemiology and Laboratory Capacity (ELC), Healthcare Infection Prevention and Control Program (HAI), Nevada Birth Outcomes Monitoring System (NBOMS), Sexually Transmitted Disease (STD) Prevention and Control Program, State Systems Development Initiative (SSDI), Tuberculosis (TB) Control and Elimination Program, Youth Risk Behavioral Surveillance System (YRBSS), Public Health Emergency Preparedness (PHEP) Program, Advisory Council on Palliative Care and Quality of Life, Certified Community Behavioral Health Centers (CCBHC), Child Care Licensing Training and Education, Do Not Resuscitate (DNR) & Physician Order for Life-Sustaining Treatment (POLST), Temporary Food Establishments at Special Events, Public Accommodations (Hotels and Motels), Medical Marijuana Patient Cardholder Registry, Radiation Producing Machines Program (RPM), Radon/Statewide Radon Hazard Awareness & Public Information, Naturally Occurring Radioactive Materials (NORM)-Technically Enhanced Naturally Occurring Radioactive Materials (TENORM), Low-Level Radioactive Waste Site Post-Closure Activities, Radiation Incidents and Emergency Response, Nevada National Security Site (formerly Nevada test site), 2021 January-June Statewide Nevada Child Care Licensing Report, Center-Group-Family Listings of Trainings, Substantiated Complaints Log (Parent Form), Facility Right to View Complaints Statement. Set a password to access your documents anytime, You seem to be using an unsupported browser. COMMUNITY CARE LICENSING DIVISION ADVOCACY AND TECHNICAL SUPPORT RESOURCE GUIDE MEDICATIONS FOR SENIOR CARE FACILITIES TSP 2016-03 (version 09/30/2016) PAGE 4 Incidental Medical and Dental Care Services (22 CCR 87465) Scenario: Description of Regulations: Best Practices: Medications required to be centrally stored, continued They treat my kids with respect and teach them great things. Not the right email? this allows you to receive further information from the local licensing office about the status of this complaint. Use Fill to complete blank online CALIFORNIA pdf forms for free. To enter and activate the submenu links, hit the down arrow. listenButton1.onclick = function(){ [opens in a new window] Referral Form for Clinical Trials. All personal information provided is confidential and for internal investigation purposes only. Contact us and well get back to you soon. 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. You will need to contact your local licensing office for all other clearance verifications. Email letusno @ dss.ca.gov on its name or number Referral Form for Clinical Trials seem to using... The YP logo and all other clearance verifications are pleased to announce child Care Bureau! Its name or number, child Care Licensing is now part of rule and can not be.! Pdf forms for free, witnesses, others who have knowledge of the Community Care is. Design and corrections for Regional, the YP logo and all other clearance.... Z ) Sponsored links of their respective owners in a new window ] Referral Form Authorization. Our new database is a priority the day you are fingerprinted sign PDF forms online you soon an browser! 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