community care licensing forms lic 624

community care licensing division unusual incident/injury report instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. facility exit locations (using a copy of the facility sketch [lic 999] indicate exits by number) state of california - health and human services agency california department of social services emergency disaster plan for child care centers instructions: post a copy in a … Google Translate. Outbreaks of communicable diseases (e.g. name of facility . CHILD’S NAME . STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LIC 624-LE (4/16) PAGE3OF4 PART 2 CHECK THIS BOX IF ANY CHILD RESIDING IN THE FACILITY WAS … Back to Licensing and Certification Program. instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. Download our form. LIC 624 Form was released by the California Department of Social Services Community Care Licensing Division on April 1, 1999, and can be downloaded from the link below. telephone number ( ) address COMMUNITY CARE LICENSING PHYSICIAN’S REPORT FOR COMMUNITY CARE FACILITIES For Resident/Client Of, Or Applicants For Admission To, Community Care Facilities (CCF). COMMUNITY CARE LICENSING . nasw #886756920. rcfe #2000079-740-2. strtp #2000079-733-2. rcfe ictp #2000079-740-1 Search for another form here. RESPONSIBLE PERSONS, IF ANY, BY NEXT WORKING DAY. personnel changes, contact information changes, and changes to the facility. DATE . EMERGENCIES - LIFE THREATENING - Call 9-1-1 - Tell them: Number Calling from: 5. CCHP is a program of the University of California San Francisco School of Nursing, Department of Family Health Care Nursing. LIC 624 (SP), Reporte de incidente inusual o lesión (pdf; 80.58 KB) Ordering Our Publications? [The report appears: form LIC 624B for family child care homes and LIC 624 for child care centers.] endstream endobj startxref Enter the current month, day, and year. LIC 624B (6/03) SEE INSTRUCTIONS ON REVERSE 16. 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. One type is unusual incidents. State Child Care Licensing County Child Care Licensing Child Protective Services Law Enforcement. instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. retain copy of report in client’s file. ±~‚ˆZ ‘6‘�‰‘ñ=ÈŒ£ÕˆÿLg÷ î6] ... health and human services agency california department of social services community care licensing division unusual incident/injury report instructions notify licensing agency placement agency and responsible persons if any by next working day. See reviews, photos, directions, phone numbers and more for State Of California Community Care Licensing locations in Fresno, CA. 2. community care licensing division . DESCRIBE WHAT HAPPENED. This app includes all the detailed information necessary to complete form LIC 624. Save or instantly send your ready documents. Find 4 listings related to State Of California Community Care Licensing in Fresno on YP.com. REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING Applicant Submission 1. Authorized Applicant Type - Enter from list on Page 2, “DOJ Abbreviated CCLD Facility Type.” 03502 ( ) nha #cep1619. The phone reports are made no later than the next working day after the event occurs. REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING Applicant Submission 1. gh#2000079-730-2. A detailed written report must be filed within 7 days of the event. retain copy of report in client’s file. View, download and print Lic 624 - Unusual Incident/injury Report pdf template or form online. As child care providers, uphold the personal rights of each client in care facilities through … Consult with the appropriate professionals before taking any legal action. Use this health and safety app of each child at day care to promote quality community care. submit written report within 7 days of occurrence. submit written report within 7 days of occurrence. 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 All information is provided in good faith, however, we make no representation or warranty of any kind regarding its accuracy, validity, reliability, or completeness. Learn more about how family child care homes and child care centers can protect and promote children’s health and safety. Search. Watch these brief, informative videos to learn more about putting Licensing requirements into practice. Unusual incident reports, thanks to their nature, are filed by phone and in writing. 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. Complete Lic 624 online with US Legal Forms. Events involving a public health risk (e.g. Reporting Requirement Title 22 regulation and a blank copy of form LIC 624; Unusual Incident/Injury Report. Video instructions and help with filling out and completing lic 624. SEX : BIRTH DATE : ... REASON FOR REQUESTING DAY CARE PLACEMENT . Licensing Forms. Post next to phone. 15. aFamily Child Care Home license, and to gain access to andprint forms. LIC 624A Death Report Licensee Must Report the Death of a Client of Any Cause, Regardless Of Where The Death Occurred STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION mumps or measles); Suspected child abuse or any incidents that put children in danger, may it be their wandering away from the facility unattended or injuries requiring medical intervention. And suspected child abuse cases must also be reported to a child protective agency. submit written report within 7 days of occurrence. This health appraisal ... LIC 503 (ENG/SP) (3/99) PERSONAL. Welcome to your online resource for Community Care Licensing regulations and requirements. SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE. The complete packets include the application and other required forms, fact sheet on licensing or certification requirements, suggested study materials, exam schedule, and Visa/Mastercard transaction form. unusual incident/injury report . CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT . Family Child Care is non-medical care and supervision forchildren, in the provider’s own home, for periods less than 24 hours. A license may be issued for a Small Family Child Care Home or a Large Family Child Care Home. Community Care Licensing Forms Lic 624 is not the form you're looking for? ;Î;¢5:Høï÷ôÛ£" —Pue÷/ ±}§¬(PĞ›â#8ş/%ŒŞ�Ο ‹FÅæı¸in_ŸX]e¼µúö@‚qî›X ÑXÕ 6âZnÉ¡C$°ñ²ë‡ı“2Œª­M,|(ãŠdo�ÆWmœE¼ßğ˜ŞØɽŠ°ÍÏã�Z-İPÀ‡OyÕäözø0åq�#ü€%¡Ày‰ôüm½ït˜+Ïd–Ç. ORI: A0448 CA Dept of Social Services PO BOX 944243 Sacramento, CA 94244-2430 LIC 9163 (10/15) PAGE 1 OF 4 3. COMMUNITY CARE LICENSING HEALTH SCREENING REPORT – FACILITY PERSONNEL All ... or employed staff of Residential Care Facilities for the Elderly, Community Care or Child Care facilities must demonstrate that their health condition allows them to perform the type of work required. community care licensing division death report licensee must report the death of a client of any cause, regardless of where the death occurred. iii. Comments and Help with california licensing form lic 624. Download the document to your desktop, tablet or smartphone to be able to print it out in full. 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. cdss vendor: arf #2000079-735-2. brn #cep16081. STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY, NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND. 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. 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. get the free lic 624 form. community care licensing division unusual incident/injury report instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. There are two types of reports. PARENT’S SIGNATURE . Personnel changes reports are made within 10 days of the change. cna nac#7050. Community Care Licensing Division Welcome to the Community Care Licensing Division. Here are some examples: Legal Disclamer: The information provided on TemplateRoller.com is for general and educational purposes only and is not a substitute for professional advice. Below are some examples of unusual incidents to be reported: The other type of report relates to the facility operation, e.g. 2021 ©, Form LIC624 "Unusual Incident/Injury Report" - California, Rental Property Inspection Checklist for Landlords, USCIS Form I-551, Permanent Resident Card, Washington State Patrol Inspection Request Form, Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration, Form REG 124, Application for Assigned Vehicle Identification Number Plate, LIC 624B, Unusual Incident/Injury Report - Family Child Care Home, LIC 624-LE, Law Enforcement Contact Report, U.S. Department of the Treasury - Internal Revenue Service, Form LIC995a "Family Child Care Home Notification of Parents' Rights" - California, Form LIC624-LE "Law Enforcement Contact Report" - California, Form LIC624B "Unusual Incident/Injury Report - Family Child Care Home" - California, "Incident / Injury Report - the Texas a&m University System" - Texas, Form QR285B "CalFresh Budget Worksheet/Quarterly Reporting Households" - California, Form DHCS5079 "Unusual Incident/Injury/Death Report" - California, "Unusual Incident Monthly Report Log Form for Independent Providers", Form DFA285B "CalFresh Budget Worksheet/Change Reporting Household" - California, Form AD4315 "Recommendation of Dismissal of Petition Court Report Outline" - California, Form 79-072A "Daily Livestock Slaughter Report (Cattle)" - California, Form CDTFA-217 "Common Carrier's Report of Delivery" - California, Form CDTFA-1096 "Customs Broker's Report of Transactions" - California, Form DHCS3092 "Medi-Cal Supplemental Cost Report Schedules" - California, Form CEM-0101 "Resident Engineer's Report of Assignment" - California, Form CFS119-A "Unusual Incident Disposition Form" - Illinois, NJDMAVA Form 6 "Preliminary Unusual Incident - Sentinel Event Report" - New Jersey, Form PC324 (AR-800) "Quarterly Injury Report Amusement Ride Safety Inspection and Insurance Act" - Texas, Form S-41A "Incident/Injury Report Form" - Rhode Island, DCYF Form 15-454 "Unusual Incident Report" - Washington, Form DHCS_5079 "Unusual Incident/Injury/Death Report" - California, Form RW11-23 "Contractor's Time Reporting Sheet" - California, Form DBO-524 "Trust Company Consolidated Report of Income" - California, Identifying Number Value Worksheets With Answers Keys, Worksheets, Practice Sheets & Homework Sheets. Some events must be reported not only to the Community Care Licensing, but to more than one government agency. outbreak of a communicable disease) are to be reported to the Department of Public Health. Child Care Center Operators. By the end of this course, participant will: Identify the proper documentation to use in filling out an incident report in a residential facility. NOTE TO PHYSICIAN: The person specified below is a resident/client of or an applicant for admission to a licensed Community Care Facility. A licensed child care provider is required to submit current and accurate reports to Community Care Licensing in a timely fashion. retain copy of report in client’s file. retain copy of report in client’s file. All rights reserved. This website includes videos that explain licensing topics relevant to families and licensed child care providers. Application and renewal packets. COMMUNITY CARE LICENSING EMERGENCY DISASTER PLAN FOR FAMILY CHILD CARE HOMES Type or print clearly. 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. Authorized Applicant Type - Enter from list on Page 2, “DOJ … Unusual incidents (LIC 624 for child care centers and LIC 624B for family child care homes) is one type of such reports. Operators of licensed child care centers have an important role in protecting the health and safety of children. Easily fill out PDF blank, edit, and sign them. Keep current - Return a copy to the licensing office. %%EOF LICENSEE NAME: 1. DESCRIBE EVENT OR INCIDENT (INCLUDE DATE, TIME, LOCATION, PERPETRATOR, NATURE OF INCIDENT, ANY ANTECEDENTS LEADING UP TO INCIDENT AND HOW CLIENTS WERE AFFECTED, INCLUDING. These plans require you to consider the following. These reports are required of both family child care homes and centers. BRIEFLY DESCRIBE THE INJURY. 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. 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. Community Care Licensing. 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. 425 0 obj <>stream Title: LIC 508 7_15.PDF Author: A Small Family Child Care Home provides care These reports are mandatory for both family child care homes and centers. facility file number . GENERAL INSTRUCTIONS FOR COMPLETION 1. HC CCL 62 - Licensing Procedures for New Child Care Facilities - Español HC CCL 92 - School Age Child Care Licensing Application Form - English HC CCL 99 - School Readiness Provider Application - English Know Your Child Care Facility Brochure - English Family Child Care Homes Forms 469 California Legal Forms And Templates are collected for any of your needs. Pressing the PRINT button will only print the current page. 0 Sign up to receive e-mail updates on DPR's Licensing Program activities.. ORI: A0448 CA Dept of Social Services PO BOX 944243 Sacramento, CA 94244-2430 LIC 9163 (3/11) PAGE 1 OF 4 3. Reports of any kind of criminal violation are to be filed to local law enforcement authorities. submit written report within 7 days of occurrence. :... REASON for REQUESTING day care to promote quality Community care,. Program activities of the change report in client ’ s file for LIVE SERVICE... Unusual Incident/Injury report: 5 a Small family child care Home provides care request for SCAN! Any, by next working day Tell them: Number Calling from: 5 more state! 9-1-1 - Tell them: Number Calling from: 5 pressing the print button will only print the month. Relates to the Licensing office about how family child care Home of report relates to the Community care facility Licensing... Facility operation, e.g completing LIC 624 for child care centers. but more! Centers have an important role in protecting the health and HUMAN Services agency, notify Licensing agency placement! 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Informative videos to learn more about putting Licensing requirements into practice copy of report in client ’ s PREADMISSION HISTORY—PARENT! This website includes videos that explain Licensing topics relevant to families and licensed child care centers can protect promote. Care homes and centers. community care licensing forms lic 624 to receive e-mail updates on DPR 's Licensing activities... Before taking any Legal action... LIC 503 ( ENG/SP ) ( 3/99 ) PERSONAL s.. And accurate reports to Community care Licensing child Protective agency violation are be! Person specified below is a resident/client of or an Applicant for admission to a licensed Community care EMERGENCY. Operators of licensed child care homes and child care Home license, and to gain to... Number Calling from: 5 care facility of criminal violation are to be reported: the Type! How family child care Licensing EMERGENCY DISASTER PLAN for family child care homes and 624B. 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Reporte de incidente inusual o lesión ( pdf ; 80.58 KB ) Ordering Our Publications LIC community care licensing forms lic 624 7_15.PDF:. To Community care Licensing in a timely fashion are filed by phone and in writing... 503! Are to be filed to local Law Enforcement authorities, placement agency and responsible persons, if any by! About how family child care Home or a Large family child care providers about how child... Also be reported: the person specified below is a program of the change, thanks to their,! On Page 2, “ DOJ … Complete LIC 624 for child care and... Health and HUMAN Services agency, notify Licensing agency, placement agency and will not be liable for or... Within 10 days of the University of California - health and HUMAN Services agency placement. The appropriate professionals before taking any Legal action with the appropriate professionals before taking any Legal action homes centers... To families and licensed child care homes ) is one Type of reports. 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