Form LIC 9224 Acknowledgement of Receipt of Licensing Reports - California

Form LIC9224 is a California Department of Social Services form also known as the "Acknowledgement Of Receipt Of Licensing Reports". The latest edition of the form was released in August 1, 2008 and is available for digital filing.

Download a PDF version of the Form LIC9224 down below or find it on California Department of Social Services Forms website.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS
I, as the parent/legal guardian of _____________________________________ , currently attending or newly enrolled at
______________________________ child care center/family child care home acknowledge I have received the following
information as required by Health and Safety Code sections 1596.8595 and 1596.8895.
Copy of any licensing report that documents a Type A deficiency cited at this facility; Type A deficiencies are those that,
if not corrected, represent an immediate risk to the health, safety or personal rights of children in care. This includes
facility visits and substantiated complaint investigations.
Date(s) of licensing report(s) provided: ________________________________________________________
Copy of licensing documents pertaining to a conference conducted by a local licensing agency management
representative and the licensee of this child care center/family child care home in which issues of noncompliance are
discussed.
Date of document provided: ____________________________
Copy of the Accusation Summary indicating the Department’s intent to revoke the license of this child care
center/family child care home, until that accusation is either dismissed or resolved through the administrative hearing
process or stipulated agreement.
Date of document provided: ________________________
As a parent/legal guardian of a newly enrolled child in this child care center/family child care home, I have been pro-
vided the documents identified above received by the licensee during the 12-month period prior to my child’s enroll-
ment.
My signature below verifies I have received the documents identified above.
PARENT/LEGAL GUARDIAN SIGNATURE:
DATE DOCUMENTS RECEIVED:
LIC 9224 (8/08)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS
I, as the parent/legal guardian of _____________________________________ , currently attending or newly enrolled at
______________________________ child care center/family child care home acknowledge I have received the following
information as required by Health and Safety Code sections 1596.8595 and 1596.8895.
Copy of any licensing report that documents a Type A deficiency cited at this facility; Type A deficiencies are those that,
if not corrected, represent an immediate risk to the health, safety or personal rights of children in care. This includes
facility visits and substantiated complaint investigations.
Date(s) of licensing report(s) provided: ________________________________________________________
Copy of licensing documents pertaining to a conference conducted by a local licensing agency management
representative and the licensee of this child care center/family child care home in which issues of noncompliance are
discussed.
Date of document provided: ____________________________
Copy of the Accusation Summary indicating the Department’s intent to revoke the license of this child care
center/family child care home, until that accusation is either dismissed or resolved through the administrative hearing
process or stipulated agreement.
Date of document provided: ________________________
As a parent/legal guardian of a newly enrolled child in this child care center/family child care home, I have been pro-
vided the documents identified above received by the licensee during the 12-month period prior to my child’s enroll-
ment.
My signature below verifies I have received the documents identified above.
PARENT/LEGAL GUARDIAN SIGNATURE:
DATE DOCUMENTS RECEIVED:
LIC 9224 (8/08)

Download Form LIC 9224 Acknowledgement of Receipt of Licensing Reports - California

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