Form LIC9040 "Child Care Facility Roster" - California

What Is LIC 9040 Form?

Form LIC 9040, Child Care Facility Roster, is a legal document completed by child care facilities to list all the children who are provided care in these facilities - child care centers, infant care centers, school-age centers, and family child care homes. Each facility must maintain individual records for its employees and individuals who receive care to be in compliance with licensing requirements and to be in a better position to respond adequately to emergency situations.

This form was issued by the California Department of Social Services (CDSS), a component of the California Health and Human Services Agency (CHHS). The latest version of the form was released on October 1, 2005, with all previous editions obsolete. You can download a fillable LIC 9040 Form through the link below.

To identify children and establish the necessary details of the people to be reached if children are involved in emergency situations, you are required to fill out Form LIC 700, Identification and Emergency Information (Child Care Centers/Family Child Care Homes).

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Form LIC 9040 Instructions

Provide the following information in the LIC 9040 Form:

  1. Add the facility details - name, license number, and the date of completion or update.
  2. Record the personal information of each child - name, date of birth, and current address. Indicate the name of the parent or legal guardian and their daytime telephone number.
  3. State the date the child was enrolled in the facility. When the child leaves, record the appropriate date.

LIC 9040 Form must be kept in a central location at the facility (for instance, administration), updated when needed, and be available to the authorities, including a licensing agency, upon request. Failure to properly maintain all required records can lead to serious problems because if critical information regarding children is missing or not readily available, it could cause a health and safety risk for children in care.

Accurate records will help the administration of the facility to address many situations - for instance, verifying children's ages to ensure the facility does not exceed the capacity permitted by the license. The document does not require signatures. You may print as many copies as needed. Gather the information when the child is first enrolled and regularly confirm with families that the details are up to date. Retain a copy of the Form LIC 9040 for at least three years.

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Download Form LIC9040 "Child Care Facility Roster" - California

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STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTE:
This roster must be kept in a central location at
the facility, updated as needed and made
CHILD CARE FACILITY ROSTER
available to the licensing agency upon request.
(RETAIN FOR 3 YEARS)
Health and Safety Code Section 1596.841 requires that each child care facility
CHILD CARE CENTERS, INFANT CARE
maintain a current roster of children who are provided care in the facility. The roster
CENTERS, SCHOOL AGE CENTERS
shall include the child’s name, address, names and day phone numbers of the
parent(s) or guardian(s) and name and phone number of the child’s physician. This is
AND FAMILY CHILD CARE HOMES
an optional form that may be used for this purpose.
FACILITY NAME:
FACILITY LICENSE NUMBER:
DATE/UPDATE:
CHILD’S NAME/
PARENT/GUARDIAN
DATE
DAYTIME PHONE OF
PHYSICIAN NAME
DATE
ADDRESS
BIRTHDATE
NAME(S)
LEFT
PARENT/GUARDIAN
AND PHONE
ENROLLED
LIC 9040 (10/05)
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTE:
This roster must be kept in a central location at
the facility, updated as needed and made
CHILD CARE FACILITY ROSTER
available to the licensing agency upon request.
(RETAIN FOR 3 YEARS)
Health and Safety Code Section 1596.841 requires that each child care facility
CHILD CARE CENTERS, INFANT CARE
maintain a current roster of children who are provided care in the facility. The roster
CENTERS, SCHOOL AGE CENTERS
shall include the child’s name, address, names and day phone numbers of the
parent(s) or guardian(s) and name and phone number of the child’s physician. This is
AND FAMILY CHILD CARE HOMES
an optional form that may be used for this purpose.
FACILITY NAME:
FACILITY LICENSE NUMBER:
DATE/UPDATE:
CHILD’S NAME/
PARENT/GUARDIAN
DATE
DAYTIME PHONE OF
PHYSICIAN NAME
DATE
ADDRESS
BIRTHDATE
NAME(S)
LEFT
PARENT/GUARDIAN
AND PHONE
ENROLLED
LIC 9040 (10/05)