Form LIC995a "Family Child Care Home Notification of Parents' Rights" - California

Form LIC 995A, Family Child Care Home Notification Of Parents' Rights, is a childcare-related form issued and distributed by the California Department of Social Services (CDSS) Community Care Licensing Division. The latest edition of the form was released by the CDSS in August 2008.

An up-to-date fillable LIC 995A form is available for download and digital filing below. Other CDSS forms can be found through the link to our CDSS forms and brochures database.

The file below requires a desktop Acrobat Reader or a browser extension to view and file. An LIC 995A Spanish version is also available by clicking this download link.

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Family Child Care Home Notification of Parents Rights

The California Code of Regulations Title 22 on admission procedures and parental and authorized representative's rights describes the rights of parents or authorized representatives of children in family child care homes as the following:

  1. The parents or representatives have the rights to visit and inspect the family child care home.
  2. They have the right to file complaints against the child care facility licensee with the local licensing office and to complain to the local licensing office and inspect the family child care home without discrimination or retaliation.
  3. They may review the family child care home's public files, reports of licensing visits and previous complaints against the licensee made during the last three years.
  4. The parents or representatives are allowed to request in writing that a parent not be allowed to visit a child or take a child from the family child care home, provided the custodial parent has shown a certified copy of a court order pursuant to Health and Safety Code Section 1596.857.

The licensee is obligated to put up the Form PUB 394, Notification of Parents' Rights - California, in a visible and accessible area of the family child care home and provide the parents or representatives with a filled-out LIC 995E, Caregiver Background Check Process.

When a child is taken into care, the licensee has to provide the child's parent or authorized representative with a copy of the LIC 995A, LIC 995E, and LIC 9212, Family Child Care Consumer Awareness Information. The licensee has to ensure that the parent or representative signs the bottom tear-away portion of the LIC 995A, which certifies that the person signing has read and is acknowledging the main statements of the LIC 995A.

This bottom portion of the form is stored in the child's personal file and can serve as proof that the parent or authorized representative has been notified of their rights and has received all of the necessary forms and paperwork from the licensee.

As soon as the parent or representative arranges for childcare services (or on the first day the child starts receiving care) the licensee has to provide that parent or representative with a copy of the LIC 995B, Addendum to Notification of Parent's Rights (Regarding Removal/Exclusion).

LIC 995A Related California Department of Social Services Forms

This list below is a compilation of the more commonly used Community Licensing Care forms required for family child care homes and childcare centers

  1. LIC 282, Affidavit Regarding Liability Insurance for Family Child Care Home;
  2. LIC 610, Emergency Disaster Plan For Child Care Facilities;
  3. LIC 610A, Emergency Disaster Plan For Family Child Care Homes;
  4. LIC 613A, Personal Rights - Child Care Facilities;
  5. LIC 624, Unusual Incident/Injury Report;
  6. LIC 624B, Unusual Incident/Injury Report - Family Child Care Homes;
  7. LIC 627, Consent For Emergency Medical Treatment - Child Care Centers Or Family Child Care Homes;
  8. LIC 700, Identification And Emergency Information Child Care Centers/Family Child Care Homes;
  9. LIC 702, Child's Preadmission Health History - Parent's Report;
  10. LIC 995, Child Care Center Notification Of Parents' Rights;
  11. LIC 995E, Important Information for Parents;
  12. LIC 995F, Caregiver Background Check Information;
  13. LIC 9040, Child Care Facility Roster;
  14. LIC 9148, Earthquake Preparedness Checklist (EPC);
  15. LIC 9149, Family Child Care Home Property Owner/Landlord Consent Form;
  16. LIC 9150, Parent Notification Additional Children In Care;
  17. LIC 9166, Nebulizer Care Consent/Verification (Child Care Facilities).
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Download Form LIC995a "Family Child Care Home Notification of Parents' Rights" - 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
NOTIFICATION OF PARENTS’ RIGHTS
PARENTS’ RIGHTS
As a Parent/Authorized Representative, you have the right to:
1.
Enter and inspect the family child care home without advance notice whenever children are in care.
2.
File a complaint against the licensee with the licensing office and review the licensee’s public file
kept by the licensing office.
3.
Review, at the family child care home, reports of licensing visits and substantiated complaints
against the licensee made during the last three years.
4.
Complain to the licensing office and inspect the family child care home without discrimination or
retaliation against you or your child.
5.
Be notified and receive, from the licensee, a written notice that lists the name of any person not
allowed in the family child care home while children are present. (NOTE: This notice is only
required when the Department has, in writing, excluded someone from the family child care
home on or after January 1, 2001).
6.
Request in writing that a parent not be allowed to visit your child or take your child from the family
child care home, provided you have shown a certified copy of a court order.
7.
Receive from the licensee the name, address and telephone number of the local licensing office.
Licensing Office Name:
_________________________________________________
Licensing Office Address:
_________________________________________________
Licensing Office Telephone #:
_________________________________________________
8.
Be informed by the licensee, upon request, of the name and type of association to the family child
care home for any adult who has been granted a criminal record exemption, and that the name of
the person may also be obtained by contacting the local licensing office.
9.
Receive, from the licensee, the Caregiver Background Check Process form.
10.
Be informed, by the licensee, that the facility has or does not have liability insurance (or a bond) that
covers injury to clients due to the negligence of the licensee or employees of the facility.
NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE FAMILY CHILD
CARE HOME TO A PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE
PARENT/AUTHORIZED REPRESENTATIVE POSES A RISK TO CHILDREN IN CARE.
For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov
(Detach Here - Give Upper Portion to Parents))
LIC 995A (8/08)
A C K N O W L E D G E M E N T O F 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
(Parent/Authorized Representative Signature Required)
I, the parent/authorized representative of_______________________________, have received a copy of the “FAMILY
CHILD CARE HOME NOTIFICATION OF PARENTS’ RIGHTS”, the CAREGIVER BACKGROUND CHECK PROCESS
and the FAMILY CHILD CARE CONSUMER AWARENESS INFORMATION form from the
licensee._____________________________________________
Name of Family Child Care Home
Signature (Parent/Authorized Representative) ______________________________________________________________Date____________________
the
NOTE: This Acknowledgement must be kept in child’s file and a copy of the Notification given to
parent/authorized representative.
For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov
LIC 995A (8/08)
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FAMILY CHILD CARE HOME
NOTIFICATION OF PARENTS’ RIGHTS
PARENTS’ RIGHTS
As a Parent/Authorized Representative, you have the right to:
1.
Enter and inspect the family child care home without advance notice whenever children are in care.
2.
File a complaint against the licensee with the licensing office and review the licensee’s public file
kept by the licensing office.
3.
Review, at the family child care home, reports of licensing visits and substantiated complaints
against the licensee made during the last three years.
4.
Complain to the licensing office and inspect the family child care home without discrimination or
retaliation against you or your child.
5.
Be notified and receive, from the licensee, a written notice that lists the name of any person not
allowed in the family child care home while children are present. (NOTE: This notice is only
required when the Department has, in writing, excluded someone from the family child care
home on or after January 1, 2001).
6.
Request in writing that a parent not be allowed to visit your child or take your child from the family
child care home, provided you have shown a certified copy of a court order.
7.
Receive from the licensee the name, address and telephone number of the local licensing office.
Licensing Office Name:
_________________________________________________
Licensing Office Address:
_________________________________________________
Licensing Office Telephone #:
_________________________________________________
8.
Be informed by the licensee, upon request, of the name and type of association to the family child
care home for any adult who has been granted a criminal record exemption, and that the name of
the person may also be obtained by contacting the local licensing office.
9.
Receive, from the licensee, the Caregiver Background Check Process form.
10.
Be informed, by the licensee, that the facility has or does not have liability insurance (or a bond) that
covers injury to clients due to the negligence of the licensee or employees of the facility.
NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE FAMILY CHILD
CARE HOME TO A PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE
PARENT/AUTHORIZED REPRESENTATIVE POSES A RISK TO CHILDREN IN CARE.
For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov
(Detach Here - Give Upper Portion to Parents))
LIC 995A (8/08)
A C K N O W L E D G E M E N T O F 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
(Parent/Authorized Representative Signature Required)
I, the parent/authorized representative of_______________________________, have received a copy of the “FAMILY
CHILD CARE HOME NOTIFICATION OF PARENTS’ RIGHTS”, the CAREGIVER BACKGROUND CHECK PROCESS
and the FAMILY CHILD CARE CONSUMER AWARENESS INFORMATION form from the
licensee._____________________________________________
Name of Family Child Care Home
Signature (Parent/Authorized Representative) ______________________________________________________________Date____________________
the
NOTE: This Acknowledgement must be kept in child’s file and a copy of the Notification given to
parent/authorized representative.
For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov
LIC 995A (8/08)