California Department of Social Services Forms

1305
total templates

Documents

1305

Form SOC873 "In-home Supportive Services (Ihss) Program Health Care Certification Form" - California

Rate (4.3 / 5) 37 votes
Size: 68 KB
2 pages

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.

Form LIC602 "Physician's Report for Community Care Facilities" - California

Rate (4.4 / 5) 70 votes
Size: 109 KB
3 pages

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.

Form LIC282 "Affidavit Regarding Liability Insurance for Family Child Care Home" - California

Rate (4.4 / 5) 87 votes
Size: 31 KB
1 page

The purpose of the form is to provide Family Child Care providers with signed confirmation from the parents or guardians of a child on the subject of liability insurance in the facility.

Form LIC601 "Identification and Emergency Information" - California

Rate (4.5 / 5) 88 votes
Size: 101 KB
2 pages

This document is filled out when an individual is admitted to a facility to establish all of the necessary details about the resident and a contact person that may be reached if the resident gets involved in an emergency situation.

Form LIC500 "Personnel Report" - California

Rate (4.4 / 5) 52 votes
Size: 194 KB
2 pages

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.

Form LIC405 "Record of Client's/Resident's Safeguarded Cash Resources" - California

Rate (4.3 / 5) 52 votes
Size: 129 KB
1 page

This form is mandatory for any facilities that handle incoming cash resources to maintain an accurate record of all sums received and distributed.

Form LIC624 "Unusual Incident/Injury Report" - California

Rate (4.4 / 5) 34 votes
Size: 68 KB
2 pages

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.

Form LIC622 "Centrally Stored Medication and Destruction Record" - California

Rate (4.6 / 5) 66 votes
Size: 268 KB
4 pages

The purpose of the document is to keep a record of centrally stored medication and to keep a record of the destruction of medication in the state of California.

Form LIC503 "Health Screening Report - Facility Personnel" - California

Rate (4.6 / 5) 70 votes
Size: 46 KB
1 page

Forms such as this are prepared by a physician in the state of California to confirm the current employee of a community care, child care, or residential care facility is healthy and fit enough to work in the facility specified in this form.

Form LIC501 "Personnel Record" - California

Rate (4.8 / 5) 64 votes
Size: 142 KB
2 pages

This document is completed by every community care employee to provide an employer with information concerning the employee's personal details and employment experience.

Form LIC622a "Medication Administration Record (MAR)" - California

Rate (4.7 / 5) 33 votes
Size: 180 KB
4 pages

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.

Form LIC9163 "Request for Live Scan Service - Community Care Licensing" - California

Rate (4.8 / 5) 41 votes
Size: 88 KB
4 pages

This form must be completed if you wish to work at, be licensed, or present at a licensed community care facility or organization.

Form LIC9182 "Criminal Background Clearance Transfer Request" - California

Rate (4.3 / 5) 60 votes
Size: 41 KB
2 pages

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.

Form LIC602A "Physician's Report for Residential Care Facilities for the Elderly (Rcfe)" - California

Rate (4.3 / 5) 42 votes
Size: 174 KB
6 pages

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

Form LIC995a "Family Child Care Home Notification of Parents' Rights" - California

Rate (4.8 / 5) 231 votes
Size: 31 KB
1 page

This form was issued and distributed by the California Department of Social Services Community Care Licensing Division. Use it for child care-related matters. The form description has explanations of parental rights related to the child care facilities, as well as a list of relevant documents.

Form LIC613A "Personal Rights - Child Care Centers" - California

Rate (4.5 / 5) 50 votes
Size: 30 KB
1 page

This is a document signed by a child's parent, guardian, or representative in order to acknowledge that a child's personal rights are observed and respected while the child is receiving services from a child care center.

Form LIC9040 "Child Care Facility Roster" - California

Rate (4.5 / 5) 66 votes
Size: 96 KB
1 page

This form must be kept by all child care centers, infant care centers, and family child care homes and be made available to the licensing agency upon request.

Form LIC9052 "Notice Employee Rights" - California

Rate (4.7 / 5) 45 votes
Size: 81 KB
1 page

This form was released by the California Department of Social Services (CDSS) and is a legal document that informs every new employee of a child care facility of their rights to file complaints against the employer for violating laws and regulations.

Form TNB4 "Notice of Recertification for Transitional Nutrition Benefit (Tnb) Program" - California

Rate (4.8 / 5) 17 votes
Size: 1 MB
2 pages

Form EFA7 "The Emergency Food Assistance Program (Tefap) Certification of Eligibility" - California

Rate (4.8 / 5) 50 votes
Size: 175 KB
2 pages

Form AAP4 "Eligibility Certification Adoption Assistance Program" - California

Rate (4.6 / 5) 30 votes
Size: 207 KB
4 pages

Form FC8 "Federal Eligibility Certification for Adoption Assistance Program" - California

Rate (4.7 / 5) 10 votes
Size: 178 KB
3 pages

Form CCP8 "Calworks Stage One Child Care Authorization Form" - California

Rate (4.8 / 5) 11 votes
Size: 141 KB
2 pages

Form FC3 "Determination of Federal AFDC-FC Eligibility" - California

Rate (4.3 / 5) 73 votes
Size: 226 KB
2 pages

Form CCP7 "Calworks Child Care Request Form and Child Care Payment Rules" - California

Rate (4.8 / 5) 71 votes
Size: 151 KB
2 pages

Form ARC2 "Redetermination: Statement of Facts Supporting Eligibility for the Approved Relative Caregiver (ARC) Funding Option Program" - California

Rate (4.4 / 5) 93 votes
Size: 159 KB
2 pages

Form SNB7 "CalFresh and Supplemental Nutrition Benefit (Snb) Informing Notice of Receiving Intercounty Transfer" - California

Rate (4.6 / 5) 7 votes
Size: 1 MB
2 pages

Form SNB8 "CalFresh and Supplemental Nutrition Benefit (Snb) Informing Notice of Sending Intercounty Transfer" - California

Rate (4.6 / 5) 19 votes
Size: 1 MB
2 pages

Form TNB7 "Transitional Nutrition Benefit (Tnb) Informing Notice of Receiving Intercounty Transfer" - California

Rate (4.5 / 5) 21 votes
Size: 1 MB
2 pages

Form TNB8 "Transitional Nutrition Benefit (Tnb) Informing Notice of Sending Intercounty Transfer" - California

Rate (4.7 / 5) 30 votes
Size: 1 MB
2 pages

Form SAR2 "Reporting Changes for Cash Aid and Calfresh" - California

Rate (4.5 / 5) 8 votes
Size: 158 KB
2 pages

Form AAP2 "Payment Instructions Adoption Assistance Program" - California

Rate (4.4 / 5) 17 votes
Size: 1 MB
2 pages

Form AAP5 "Adoptions Assistance Program Independent Adoptions Program" - California

Rate (4.5 / 5) 17 votes
Size: 1 MB
1 page

Form AAP6 "Adoption Assistance Program Negotiated Benefit Amount and Approval" - California

Rate (4.5 / 5) 11 votes
Size: 1 MB
5 pages

Form AAP8 "Adoption Assistance Program Nonrecurring Adoption Expenses Agreement" - California

Rate (4.6 / 5) 17 votes
Size: 1 MB
1 page

Form SNB2 "Notice of Approval for Supplemental Nutrition Benefit (Snb) Program" - California

Rate (4.9 / 5) 7 votes
Size: 1 MB
2 pages

Form SNB4 "Notice of Expiration of Certification for Supplemental Nutrition Benefit (Snb) Program" - California

Rate (4.3 / 5) 10 votes
Size: 1 MB
2 pages

Form SNB5 "Notice of Discontinuance for Supplemental Nutrition Benefit (Snb) Program" - California

Rate (4.4 / 5) 13 votes
Size: 1 MB
2 pages

Form SNB3 "Notice of Change for Supplemental Nutrition Benefit (Snb) Program" - California

Rate (4.7 / 5) 15 votes
Size: 1 MB
2 pages

Form TNB2 "Notice of Approval for Transitional Nutrition Benefit (Tnb) Program" - California

Rate (4.7 / 5) 17 votes
Size: 1 MB
2 pages