Form LIC9182 "Criminal Background Clearance Transfer Request" - California

What Is LIC 9182 Form?

Form LIC 9182, Criminal Background Clearance Transfer Request is a document used to apply for a transfer of an active criminal record from one state licensed facility to another. This is a state-specific form designed and issued by the California Department of Social Services Community Care Licensing Division. The most recent version of the form was released in November 2015. Download the up-to-date LIC 9182 fillable form through the link below.

California state law demands fingerprints of all the community care license applicants. This requirement includes adults who are employees at licensed community care facilities or home care organizations, and home care aide applicants, both independent and affiliated to a home care organization. The initial community care licensing fingerprint clearance or the Community Care Licensing Division (CCLD) fingerprint clearance is provided by the Caregiver Background Check Bureau.

After the clearance was granted, it can be transferred from one facility to another. For this purpose, a license applicant or a licensee must submit an LIC 9182 Form. To avoid delays during the transfer processing, you are not required to be re-fingerprinted if you already have an active clearance. To verify your status, contact your local CCLD office.

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Form LIC 9182 Instructions

The instructions for the Criminal Background Clearance Transfer Request include the following:

  1. Use this form to request only a transfer of an active criminal record clearance. If you need to transfer an active exemption, submit Form LIC 9188, Criminal Record Exemption Transfer;
  2. Fill out Form LIC 9182 to transfer clearance between state-licensed facilities only. To request a transfer from the TrustLine Registry, use the Form TLR 3, Trustline to Community Care Licensing Criminal Background Clearance Transfer Request;
  3. You may request a transfer of criminal background clearance to more than one facility on one form. For this purpose, attach a list containing the facility number for each facility to which the clearance should be transferred;
  4. The form must be submitted before the individual subject to transfer has asses to the facility clients;
  5. If the individual starts working at the facility before the criminal background clearance transfer request is submitted, the community care facility or organization will be subject to a civil penalty. The amount of the penalty is $100;
  6. The licensee or the license applicant must attach Form LIC 508 and a copy of the permanent resident card, the individual's driver license, or any valid photo identification to Form LIC 9182. Moreover, if the individual is transferred to a facility serving children, a Child Abuse Central Index Check must be submitted;
  7. The Social Security number (SSN) box on this form is optional. However, it is often used as an identifying number and failure to provide the SSN may delay the processing of this transfer request;
  8. The individual seeking for transfer does not need to wait for a confirmation of the clearance transfer. As soon as the transfer request form is submitted, the individual can start working in the facility.

Where to Send LIC 9182?

Submit the form to a local CCLD office. Find the list of all local offices and their contact information on the California Department of Social Services (CDSS) website. Individuals who wish to receive a community care license, provide services, work or reside in a licensed community care facility will need to fill out two more forms:

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Download Form LIC9182 "Criminal Background Clearance Transfer Request" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CRIMINAL BACKGROUND CLEARANCE TRANSFER REQUEST
Active criminal record clearances may be transferred from one state licensed facility/organization to another by a license
applicant or licensee. The transfer request must be submitted to the Department before the individual who is the
subject of the transfer has client contact or the facility/organization will be in violation of the law and subject to a
$100 civil penalty.
The license applicant or licensee who is seeking the transfer must provide a LIC 508, and verify the individual’s identity and
include a copy of the person’s driver’s license, permanent resident card or a valid photo identification issued by the
California Department of Motor Vehicles or by another state or the United States government if the person is not a California
resident. Additionally, a Child Abuse Central Index (CACI) check must be submitted if the transfer is to a facility serving
children and the individual has not previously submitted a CACI check or the date of the previous CACI inquiry was made
prior to January 1, 1999. The CACI must be mailed directly to the Department of Justice with the applicable fee. Note: This
transfer request is for clearances only. Contact your licensing office for information about exemption transfers.
This form may only be used to request a clearance transfer between state licensed facilities/organizations. To request a
transfer between county and state licensed facilities, the requesting Licensing Agency must contact their county liaison.
DATE:
PLEASE TYPE OR PRINT LEGIBLY
PLEASE TRANSFER THE CRIMINAL RECORD CLEARANCE FOR THE FOLLOWING INDIVIDUAL:
LAST NAME
FIRST NAME
MIDDLE INITIAL
CA DRIVER’S LICENSE OR ID #/PERMANENT RESIDENT ID# (i-551):
DOB:
LICENSING INFORMATION SYSTEM ID#:
SSN: (OPTIONAL)
FROM THE FOLLOWING FACILITY/ORGANIZATIONS:
NAME OF FACILITY/ORGANIZATION:
FACILITY/ORGANIZATION NUMBER:
STREET ADDRESS:
CITY
STATE
ZIP CODE:
TO THE FOLLOWING FACILITY/ORGANIZATION:
PLEASE ALSO KEEP THIS INDIVIDUAL ASSOCIATED WITH
ABOVE FACILITY/ORGANIZATION.
NAME OF FACILITY/ORGANIZATION:
Transferee Association Type
Facility Administrator
Corporation Board Member
FACILITY/ORGANIZATION NUMBER:
DATE OF EMPLOYMENT:
Employee
Certified Home
STREET ADDRESS:
Licensee/Applicant
Non-client Adult Resident
Partnership Member
CITY
STATE
ZIP CODE:
Spouse of Licensee
Affiliated Home Care Aide
I certify I have verified the above individual’s identity and have enclosed a copy
Title (licensee, administrator, director)
of the individual’s photo I.D and LIC 508.
Signature
FOR DISTRICT OFFICE USE ONLY
DATE OF TRANSFER ENTRY:
INITIAL OF PERSON ENTERING TRANSFER:
FILE IN NEWLY ASSOCIATED FACILITY/ORGANIZATION FILE
LIC 9182 (11/15)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CRIMINAL BACKGROUND CLEARANCE TRANSFER REQUEST
Active criminal record clearances may be transferred from one state licensed facility/organization to another by a license
applicant or licensee. The transfer request must be submitted to the Department before the individual who is the
subject of the transfer has client contact or the facility/organization will be in violation of the law and subject to a
$100 civil penalty.
The license applicant or licensee who is seeking the transfer must provide a LIC 508, and verify the individual’s identity and
include a copy of the person’s driver’s license, permanent resident card or a valid photo identification issued by the
California Department of Motor Vehicles or by another state or the United States government if the person is not a California
resident. Additionally, a Child Abuse Central Index (CACI) check must be submitted if the transfer is to a facility serving
children and the individual has not previously submitted a CACI check or the date of the previous CACI inquiry was made
prior to January 1, 1999. The CACI must be mailed directly to the Department of Justice with the applicable fee. Note: This
transfer request is for clearances only. Contact your licensing office for information about exemption transfers.
This form may only be used to request a clearance transfer between state licensed facilities/organizations. To request a
transfer between county and state licensed facilities, the requesting Licensing Agency must contact their county liaison.
DATE:
PLEASE TYPE OR PRINT LEGIBLY
PLEASE TRANSFER THE CRIMINAL RECORD CLEARANCE FOR THE FOLLOWING INDIVIDUAL:
LAST NAME
FIRST NAME
MIDDLE INITIAL
CA DRIVER’S LICENSE OR ID #/PERMANENT RESIDENT ID# (i-551):
DOB:
LICENSING INFORMATION SYSTEM ID#:
SSN: (OPTIONAL)
FROM THE FOLLOWING FACILITY/ORGANIZATIONS:
NAME OF FACILITY/ORGANIZATION:
FACILITY/ORGANIZATION NUMBER:
STREET ADDRESS:
CITY
STATE
ZIP CODE:
TO THE FOLLOWING FACILITY/ORGANIZATION:
PLEASE ALSO KEEP THIS INDIVIDUAL ASSOCIATED WITH
ABOVE FACILITY/ORGANIZATION.
NAME OF FACILITY/ORGANIZATION:
Transferee Association Type
Facility Administrator
Corporation Board Member
FACILITY/ORGANIZATION NUMBER:
DATE OF EMPLOYMENT:
Employee
Certified Home
STREET ADDRESS:
Licensee/Applicant
Non-client Adult Resident
Partnership Member
CITY
STATE
ZIP CODE:
Spouse of Licensee
Affiliated Home Care Aide
I certify I have verified the above individual’s identity and have enclosed a copy
Title (licensee, administrator, director)
of the individual’s photo I.D and LIC 508.
Signature
FOR DISTRICT OFFICE USE ONLY
DATE OF TRANSFER ENTRY:
INITIAL OF PERSON ENTERING TRANSFER:
FILE IN NEWLY ASSOCIATED FACILITY/ORGANIZATION FILE
LIC 9182 (11/15)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PRIVACY STATEMENT
Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code section 1798 et seq.),
notice is given for the request of the Social Security Number (SSN) on this form. The California Department of Justice uses a
person’s SSN as an identifying number. The requested SSN is voluntary. Failure to provide the SSN may delay the processing of
this form and the criminal record check.
In order to be licensed, work at, or be present at, a licensed facility/organization, the law requires that you complete a criminal
background check. (Health and Safety Code sections 1522, 1568.09, 1569.17, 1596.871 and 1796.19). The Department will
create a file concerning your criminal background check that will contain certain documents, including information that you
provide. You have the right to access certain records containing your personal information maintained by the Department (Civil
Code section 1798 et seq.). Under the California Public Records Act, the Department may have to provide copies of some of
the records in the file to members of the public who ask for them, including newspaper and television reporters.
NOTE: IMPORTANT INFORMATION
The Department is required to tell people who ask, including the press, if someone in a licensed facility/organization has a
criminal record exemption. The Department must also tell people who ask the name of a licensed facility/organization that has a
licensee, employee, resident, or other person with a criminal record exemption.
If you have any questions about this form, please contact your local licensing regional office.
LIC 9182 (11/15)
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