Form LIC-507 Facilities Staff Work Schedule - California

Form lic-507 or the "Facilities Staff Work Schedule" is a form issued by the California Department of Social Services.

The form was last revised in January 1, 2000 and is available for digital filing. Download an up-to-date fillable Form lic-507 in PDF-format down below or look it up on the California Department of Social Services Forms website.

ADVERTISEMENT
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
FACILITIES STAFF WORK SCHEDULE
INSTRUCTIONS: This form is to be completed by the licensing evaluator and reviewed by the licensing supervisor.
The purpose of this form is to review staff coverage in large Residential Facilities for 24-hours per day covering a (3) three-week period to
ensure sufficient staff coverage. CAREFULLY review split shifts, weekend coverage and irregular days off to ensure sufficient staff coverage.
FACILITY NAME
FACILITY NUMBER
FACILITY TYPE
FACILITY CAPACITY
CLIENT/RESIDENT CENSUS
LICENSING EVALUATOR
DATE
Enter Dates of Week
Enter Dates of Week
Enter Dates of Week
For The Month(s)
20
SERVICE AREA AND WORK TITLE
Sun
Mon Tues Wed Thurs Fri
Sat
Sun Mon Tues Wed Thurs Fri
Sat
Sun Mon Tues Wed Thurs Fri
Sat
1.
Care and Supervision (e.g., Aides)
Enter Work Hours
Enter Work Hours
Enter Work Hours
Employee Name(s)
2.
Food Services (e.g, includes cook, dishwasher)
Employee Name(s)
LIC 507 (1/00)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
FACILITIES STAFF WORK SCHEDULE
INSTRUCTIONS: This form is to be completed by the licensing evaluator and reviewed by the licensing supervisor.
The purpose of this form is to review staff coverage in large Residential Facilities for 24-hours per day covering a (3) three-week period to
ensure sufficient staff coverage. CAREFULLY review split shifts, weekend coverage and irregular days off to ensure sufficient staff coverage.
FACILITY NAME
FACILITY NUMBER
FACILITY TYPE
FACILITY CAPACITY
CLIENT/RESIDENT CENSUS
LICENSING EVALUATOR
DATE
Enter Dates of Week
Enter Dates of Week
Enter Dates of Week
For The Month(s)
20
SERVICE AREA AND WORK TITLE
Sun
Mon Tues Wed Thurs Fri
Sat
Sun Mon Tues Wed Thurs Fri
Sat
Sun Mon Tues Wed Thurs Fri
Sat
1.
Care and Supervision (e.g., Aides)
Enter Work Hours
Enter Work Hours
Enter Work Hours
Employee Name(s)
2.
Food Services (e.g, includes cook, dishwasher)
Employee Name(s)
LIC 507 (1/00)
FACILITY NAME/NUMBER
FACILITY STAFF WORK SCHEDULE (Continued)
Enter Dates of Week
Enter Dates of Week
Enter Dates of Week
For The Month(s)
20
SERVICE AREA AND WORK TITLE
Sun
Mon Tues Wed Thurs Fri
Sat
Sun Mon Tues Wed Thurs Fri
Sat
Sun Mon Tues Wed Thurs Fri
Sat
3.
Housekeeping (e.g. Maid)
Enter Work Hours
Enter Work Hours
Enter Work Hours
Employee Name(s)
4.
Administrative/Clerical Staff
Employee Name(s)
5.
Transportation/Maintenance
Employee Name(s)
6.
Other
(specify other service areas below)
Employee Name(s)
Page 2

Download Form LIC-507 Facilities Staff Work Schedule - California

1202 times
Rate
4.5(4.5 / 5) 84 votes
ADVERTISEMENT
Page of 2