California Department of Social Services Forms




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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.

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.


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.

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

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.

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.

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.

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

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.

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

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.

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

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.

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.

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.

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.

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