Form LIC857 "Children's Records Review (Child Care Center)" - California

What Is Form LIC857?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2006;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form LIC857 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form LIC857 "Children's Records Review (Child Care Center)" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
INSTRUCTIONS: When reviewing client/child records in a facility enter appropriate code in each column.
x
– Document required for facility category is complete and current
CHILDREN’S RECORDS REVIEW
o
– Document is lacking, incomplete or requires updating
N/A – Not applicable
(CHILD CARE CENTER)
Any item shown as "o" shall be documented on the Licensing Report (LIC 809) with a plan
of correction date. File this form in the facility file.
FACILITY NAME
LICENSE REPORT (LIC 809) DATE
FACILITY NUMBER
TYPE OF VISIT
PRELICENSING
EVALUATION
FOLLOW-UP
COMPLAINT
CONSENT FOR
PARENT'S
EMERGENCY
FULL TIME
IMMUNIZA-
PERSONAL
I.D. AND
RIGHTS
DATE
*REFERENCE
NAME
DATE
ADMISSION
HEALTH
PHYSICIAN
T.B. TEST
MEDICAL
OR
TION
RIGHTS
EMERGENCY
RECEIPT
OF
NUMBER
ENROLLED
AGREEMENT
HISTORY
REPORT
TREATMENT
PART TIME
RECORD
(LIC 613A)
INFO
(LIC 995)
BIRTH
(LIC 627)
LICENSING EVALUATOR SIGNATURE
LICENSING EVALUATOR NAME (PRINT)
DATE
*
PAGE
OF
Reference number corresponds to number used on the licensing report.
LIC 857 (8/06) CONFIDENTIAL
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
INSTRUCTIONS: When reviewing client/child records in a facility enter appropriate code in each column.
x
– Document required for facility category is complete and current
CHILDREN’S RECORDS REVIEW
o
– Document is lacking, incomplete or requires updating
N/A – Not applicable
(CHILD CARE CENTER)
Any item shown as "o" shall be documented on the Licensing Report (LIC 809) with a plan
of correction date. File this form in the facility file.
FACILITY NAME
LICENSE REPORT (LIC 809) DATE
FACILITY NUMBER
TYPE OF VISIT
PRELICENSING
EVALUATION
FOLLOW-UP
COMPLAINT
CONSENT FOR
PARENT'S
EMERGENCY
FULL TIME
IMMUNIZA-
PERSONAL
I.D. AND
RIGHTS
DATE
*REFERENCE
NAME
DATE
ADMISSION
HEALTH
PHYSICIAN
T.B. TEST
MEDICAL
OR
TION
RIGHTS
EMERGENCY
RECEIPT
OF
NUMBER
ENROLLED
AGREEMENT
HISTORY
REPORT
TREATMENT
PART TIME
RECORD
(LIC 613A)
INFO
(LIC 995)
BIRTH
(LIC 627)
LICENSING EVALUATOR SIGNATURE
LICENSING EVALUATOR NAME (PRINT)
DATE
*
PAGE
OF
Reference number corresponds to number used on the licensing report.
LIC 857 (8/06) CONFIDENTIAL