Form LIC-507 "Facilities Staff Work Schedule" - California

What Is Form LIC-507?

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 January 1, 2000;
  • 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 LIC-507 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 LIC-507 "Facilities Staff Work Schedule" - California

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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)
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