Form LIC500 "Personnel Report" - California

What Is LIC 500 Form?

Form LIC 500, Personnel Report is a state-specific form filled out to provide a current list of the personnel employed on the facility. Besides the employees, the list has to include backup persons, volunteers, and other adults and licensees residing in the facility. Download the up-to-date fillable Form LIC 500 through the link below.

Alternate Names:

  • California Department of Social Services (CDSS) Personnel Report;
  • LIC Personnel Report.

The document was issued by the Community Care Licensing Division within the California Department of Social Services (CDSS). The latest revision of Form LIC 500 was released on November 1, 2003.

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Form LIC 500 Instructions

Form LIC 500 is necessary for keeping the current list of all staff working and residing in the facility. The regulations require you to report any changes in the personnel to the licensing agency immediately. The completed form must show that twenty-four-hour supervision is provided at the residential facility. If you have hired specialized employees who require a license or certificate, like a social worker or another consultant, specify the number of the licenses on this form.

The LIC Personnel Report is a two-page document. The form should be filled out by a licensee or a designated representative. Check the step-by-step guide to facilitate the filing process:

  1. Provide the basic information about the facility, including its name, type, and facility number. Specify your name and the date of completion.
  2. Table A, Staff Subject to Criminal Background Check Requirements. List all personnel subject to a criminal background check in this table. Remember that before the employment, residence, or initial presence of every person listed, the facility must obtain either a California background clearance or a criminal record exemption. Otherwise, the facility may be subject to an administrative penalty. The columns of this table are self-explanatory. You are required to specify the name, job title, date of employment (if applicable), and days and hours on duty for each staff member subject to a criminal background check.
  3. Table B, Staff Exempt From Criminal Background Check Requirements. This table should contain the list of all individuals (employed at your facility) you believe exempt from criminal background check requirements according to the laws and regulations. Sign the page to verify your statement and indicate the date of the signature. Do not complete this page if you presume there is no individual exempt from criminal background check requirements. This table requires the same information as Table A. It should include the names, employment dates, job titles, and schedules of the individuals exempt from criminal background check requirements.
  4. Fill out the two copies of the form. Send the original to the licensing agency and keep a copy for the facility records.

The LIC 500 Form is often submitted while applying for a facility license. It is necessary to ensure that the facility planned the staff to adequately operate the facility and that the staff presented is large enough for the facility to work in compliance with the local law and regulations. When submitted during the application phase, the form should list all the planned employee positions and include the days and hours the personnel is scheduled to perform their duties. It is possible, that the facilities have not hired all the staff they need at the stage of the license application. In this case, the designated employees and placeholders for positions should be listed in the form as "to be hired".

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Download Form LIC500 "Personnel Report" - California

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STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
INSTRUCTIONS:
This form is intended for keeping a current roster of all the facility personnel, other adults and licensees residing in the facility,
PERSONNEL REPORT
including backup persons, volunteers and licensee if administrator/director. Show license/certificate number if applicable for
specialized staff [e.g., Social Worker and other consultant(s)]. Show coverage for twenty-four hour supervision in residential
facilities. Report any changes in personnel to the licensing agency as required by regulations. Send original to Licensing
Agency and retain copy in facility file.
NAME OF FACILITY
FACILITY TYPE
FACILITY NUMBER
PREPARED BY
DATE
A.
STAFF SUBJECT TO CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following staff members are subject to a criminal background check pursuant to Sections 1522, 1568.09, 1569.17 and
1596.871 of the Health and Safety Code. A California background clearance or a criminal record exemption shall be obtained prior to employment, residence or initial presence in the facility.
SPECIFY
SPECIFY
SPECIFY
DATE
DAYS AND HOURS ON DUTY
DAYS AND HOURS ON DUTY
DAYS AND HOURS ON DUTY
NAME
JOB TITLE
EMPL'D
DAYS
FROM
TO
DAYS
FROM
TO
DAYS
FROM
TO
Licensee/Administrator
Page 1 of 2
LIC 500 (11/03) (PUBLIC)
STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
INSTRUCTIONS:
This form is intended for keeping a current roster of all the facility personnel, other adults and licensees residing in the facility,
PERSONNEL REPORT
including backup persons, volunteers and licensee if administrator/director. Show license/certificate number if applicable for
specialized staff [e.g., Social Worker and other consultant(s)]. Show coverage for twenty-four hour supervision in residential
facilities. Report any changes in personnel to the licensing agency as required by regulations. Send original to Licensing
Agency and retain copy in facility file.
NAME OF FACILITY
FACILITY TYPE
FACILITY NUMBER
PREPARED BY
DATE
A.
STAFF SUBJECT TO CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following staff members are subject to a criminal background check pursuant to Sections 1522, 1568.09, 1569.17 and
1596.871 of the Health and Safety Code. A California background clearance or a criminal record exemption shall be obtained prior to employment, residence or initial presence in the facility.
SPECIFY
SPECIFY
SPECIFY
DATE
DAYS AND HOURS ON DUTY
DAYS AND HOURS ON DUTY
DAYS AND HOURS ON DUTY
NAME
JOB TITLE
EMPL'D
DAYS
FROM
TO
DAYS
FROM
TO
DAYS
FROM
TO
Licensee/Administrator
Page 1 of 2
LIC 500 (11/03) (PUBLIC)
B.
STAFF EXEMPT FROM CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following are believed exempt from criminal background check requirements pursuant to Sections 1522, 1568.09,
1569.17 and 1596.871 of the Health and Safety Code. The licensee or designated representative shall sign below to verify that he or she believes the indicated persons are exempt from criminal background
check requirements pursuant to statute.
Signature ________________________________________________________________________________ Date __________________
SPECIFY
SPECIFY
SPECIFY
DATE
NAME
JOB TITLE
DAYS AND HOURS ON DUTY
DAYS AND HOURS ON DUTY
DAYS AND HOURS ON DUTY
EMPL'D
DAYS
FROM
TO
DAYS
FROM
TO
DAYS
FROM
TO
Page 2 of 2
Page of 2