Form LIC995B "Family Child Care Home Addendum to Notification of Parents' Rights (Regarding Removal/Exclusion) State of California - Health and Human Services Agency" - California

What Is Form LIC995B?

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 August 1, 2008;
  • 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 LIC995B 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 LIC995B "Family Child Care Home Addendum to Notification of Parents' Rights (Regarding Removal/Exclusion) State of California - Health and Human Services Agency" - California

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STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FAMILY CHILD CARE HOME
ADDENDUM TO NOTIFICATION OF PARENTS’ RIGHTS
(REGARDING REMOVAL/EXCLUSION)
California State law requires the licensee to notify you that the person whose name appears below has been
removed or excluded from this Family Child Care Home.
Name:
_____________________________________________________
Effective Date:
_____________________________________________________
This person is not permitted to be in the home at any time when children are in care. This
removed/excluded person may be an ex-employee, friend or relative of the licensee. This person has a right
to appeal the exclusion. If he/she is later permitted back into the Family Child Care Home you will be
notified.
The local licensing office listed below maintains a public file on this facility. Parents, domestic partners or
authorized representatives may review the public file for any documents related to this action. You should
know that many documents are protected by confidentiality laws and will not be available for review.
Licensing Office Name:
_____________________________________________________
Licensing Office Address:
_____________________________________________________
City/State/Zip:
_____________________________________________________
Name And Address of This Facility
Facility Name:
_____________________________________________________
Facility Address:
_____________________________________________________
City/State/Zip:
_____________________________________________________
A C K N O W L E D G M E N T O F
A D D E N D U M T O N O T I F I C AT I O N O F PA R E N T S ’ R I G H T S
( R E G A R D I N G R E M O VA L / E X C L U S I O N )
This will acknowledge that I, the parent/authorized representative of ______________________,
h a v e r e c e i v e d a c o py o f t h e “ A D D E N D U M TO N OT I F I C AT I O N O F PA R E N T S ’ R I G H T S
( R E G A R D I N G R E M OVA L / E X C L U S I O N ) ” f r o m t h e l i c e n s e e o r d e s i g n a t e d r e p r e s e n t a t i ve.
(Parent /Authorized Representative signature is required) .
______________________________________________
_______________________
Signature of Parent/Authorized Representative
Date
NOTE: This form with the original signature of the parent/authorized representative must be kept in
the child’s file. A copy of this form must be given to the parent/authorized representative.
LIC 995B (8/08)
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FAMILY CHILD CARE HOME
ADDENDUM TO NOTIFICATION OF PARENTS’ RIGHTS
(REGARDING REMOVAL/EXCLUSION)
California State law requires the licensee to notify you that the person whose name appears below has been
removed or excluded from this Family Child Care Home.
Name:
_____________________________________________________
Effective Date:
_____________________________________________________
This person is not permitted to be in the home at any time when children are in care. This
removed/excluded person may be an ex-employee, friend or relative of the licensee. This person has a right
to appeal the exclusion. If he/she is later permitted back into the Family Child Care Home you will be
notified.
The local licensing office listed below maintains a public file on this facility. Parents, domestic partners or
authorized representatives may review the public file for any documents related to this action. You should
know that many documents are protected by confidentiality laws and will not be available for review.
Licensing Office Name:
_____________________________________________________
Licensing Office Address:
_____________________________________________________
City/State/Zip:
_____________________________________________________
Name And Address of This Facility
Facility Name:
_____________________________________________________
Facility Address:
_____________________________________________________
City/State/Zip:
_____________________________________________________
A C K N O W L E D G M E N T O F
A D D E N D U M T O N O T I F I C AT I O N O F PA R E N T S ’ R I G H T S
( R E G A R D I N G R E M O VA L / E X C L U S I O N )
This will acknowledge that I, the parent/authorized representative of ______________________,
h a v e r e c e i v e d a c o py o f t h e “ A D D E N D U M TO N OT I F I C AT I O N O F PA R E N T S ’ R I G H T S
( R E G A R D I N G R E M OVA L / E X C L U S I O N ) ” f r o m t h e l i c e n s e e o r d e s i g n a t e d r e p r e s e n t a t i ve.
(Parent /Authorized Representative signature is required) .
______________________________________________
_______________________
Signature of Parent/Authorized Representative
Date
NOTE: This form with the original signature of the parent/authorized representative must be kept in
the child’s file. A copy of this form must be given to the parent/authorized representative.
LIC 995B (8/08)