California Department of Social Services Forms

Download this form, which is a medical certification submitted by a licensed health care professional to sanction the disabled, blind, or elderly access for services from the In-Home Supportive Services (IHSS) program.

File this form if you are the physician of the applicant for admission to a Community Care Facility and have a thorough knowledge of the patient's medical issues. The goal of this document is to check if the patient can continue their residential treatment at the facility.

This is form issued by the California Department of Social Services (CDSS). It is filed to keep a current list of the staff (including backup persons, volunteers, etc.) employed and residing on the facility.

This document is also known as the LIC injury report form. It is an application intended for daycare providers used to report unusual incidents to the appropriate California state organizations.

Use this form if you are health care professional to keep track of non-psychotropic medications prescribed to a child. This four-page record sheet is often referred to as a drug chart.

File this document if you are an employee of a licensed community care facility or home care organization, and wish to apply for a transfer of your active criminal record from one state licensed facility to another.

Download this document to inform your residential care facility of care needs, diagnosis, and mental condition of an elderly person.