Forms. See our locations servicing Fresno, Merced, Tulare/Kings, Madera, and Mariposa Counties. Salt Lake City, Ut 84116, DLBC Contact Info The Live Scan Operator will complete section 8. Staffing Plan: Child Care Center CCL-5001 - Word Let Us No to submit a complaint. To enter and activate the submenu links, hit the down arrow. | A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z |, Admission Agreement For Residential Care Facilities For The Elderly LIC 604A, Admission Agreement Guide For Residential Facilities LIC 604, Affidavit Regarding Client/Resident Cash Resources LIC 400, Affidavit Regarding Liability Insurance For Family Child Care Home LIC 282, Annual License Fee Notice County LIC 201F, Applicant Fingerprint Follow-Up Request LIC 107, Application for a Child Care Center License LIC 200A, Application For A Community Care Facility or Residential Care Facility For The Elderly License LIC 200, Application For A Family Child Care Home License LIC 279, Application Instructions for A Facility License LIC 281, Appraisal/Needs And Services Plan LIC 625, Balance Sheet Supplemental Schedule LIC 403A, Centrally Stored Medication And Destruction Record LIC 622, Certificate Of Approval (For Certified Family Homes) LIC 229, Child Abuse Central Index Check For County Licensed Facilities -LIC 198, Child Abuse Central Index Check For State Licensed Facilities LIC 198A, Childs Preadmission Health History Parents Report LIC 702, Civil Penalty Assessment Immediate LIC 421B, Civil Penalty Assessment (Unlicensed Facility) LIC 421A, Civil Penalty Ledger Payment, Reduction, Or Waiver Record LIC 422A, Client/Resident Personal Property And Valuables LIC 621, Confidential Report Not Subject To Public Disclosure Report Of Suspected Dependent Adult/Elder Abuse SOC 341, Consent For Emergency Medical Treatment Child Care Centers Or Family Child Care Homes LIC 627, Consent For Emergency Medical Treatment Childrens Residential Facilities LIC 627B, Consent For Emergency Medical Treatment Adult And Elderly Residential Facilities LIC 627C, Consent To A Medical Examination LIC 627A, Criminal Background Clearance Transfer Request LIC 9182, Criminal Record Statement Adoption Facilitator LIC 508A, Criminal Record Statement Long-Term Ombudsman Program LIC 508B, Current Children In Your Home Application For A Family Child Care Home License LIC 279B, Designation Of Facility Responsibility LIC 308, Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities LIC 610D, Emergency Disaster Plan For Child Care Centers LIC 610, Emergency Disaster Plan For Childrens Residential Facilities (Except Foster Family Homes) LIC 610C, Emergency Disaster Plan For Family Child Care Homes LIC 610A, Emergency Disaster Plan For Residential Care Facilities For The Elderly LIC 610E, Emergency Plan For Foster Family Homes LIC 610B, Financial Information Release And Verification LIC 404, Forms/Records To Keep In Your Family Child Care Home LIC 311D, Foster Family Home Application Instructions LIC 283A, Gastrostomy Tube Care: Physicians Checklist (Child Care Facilities) LIC 701A, Gastrostomy Tube Care Consent/Verification (Child Care Facilities) LIC 701B, Health Screening Report Facility Personnel LIC 503, Identification And Emergency Information LIC 601, Identification And Emergency Information Child Care Centers/Family Child Care Homes LIC 700, License Application And Instructions For Child Care Centers LIC 281A, License Application And Instructions For Family Child Care Homes LIC 279A, Notice Of Operation In Violation Of Law LIC 195, Notice Of Operation In Violation Of Law Family Child Care Home LIC 195A, Notification Of Incomplete Application LIC 184, Notification Of Incomplete Foster Family Home Application LIC 184A, Notification Of Initial Application Denial LIC 192, Orientation Meeting Family Child Care Home LIC 186A, Out-Of-State Child Abuse/Neglect Report Request LIC 198B, Out-Of-State Disclosure And Criminal Record Statement LIC 508D, Personal Rights Child Care Centers LIC 613A, Personal Rights Childrens Residential Facilities LIC 613B, Personal Rights Adult Residential Care Facilities LIC 613, Personal Rights Residential Care Facilities for The Elderly (Publicly Operated) LIC 613C, Personal Rights Residential Care Facilities for The Elderly (Privately Operated) LIC 613C-2, Physicians Report Child Care Centers LIC 701, Physicians Report For Community Care Facilities LIC 602, Physicians Report For Residential Care Facilities For The Elderly (RCFE) LIC 602A, Pre-placement Appraisal Information LIC 603, Record Of Clients Cash Resources For Change Of Licensee LIC 424, Record Of Clients/Residents Safeguarded Cash Resources LIC 405, Records To Be Maintained At The Facility Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children LIC 311A, Records To Be Maintained At The Facility Adult Residential LIC 311C, Records To Be Maintained At The Facility Small Family Home And Foster Family Home LIC 311E, Records To Be Maintained At The Facility Residential Care Facility For The Elderly LIC 311F, Records To Be Maintained By The Facility Group Homes LIC 311B, Reference Request Adoption Facilitator LIC 301A, Reference Request Long-Term Care Ombudsman Program LIC 301B, Release Of Client/Resident Medical Information LIC 605A, Removal Confirmation Exemption Needed LIC 300A, Removal Confirmation Non-Exemptible LIC 300D, Removal Confirmation Rescinded LIC 300C, Reporting Requirements By Licensees To The State Department Of Social Services LIC 306, Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders SOC 341a, Supplemental Financial Information LIC 401A, Unusual Incident/Injury Report Family Child Care Home LIC 624B, Your Right To Make Decisions About Medical Treatment PUB 325, If you don't see what you're looking for, please give us a call at 530-894-2114. Call: (888) 287-3704 Certification of School Building Fire Safety Provisions CCL-5043 - Word, Self-Certification of Transportation Provisions for Centers CCL-5044 - PDF (By clicking on the Adobe website link, you will leave the VHA OCC website. You will recieve an email notification when the document has been completed by all parties. This is to make the processes more efficient. Designation Of Administrative Responsibility (Lic 308), Affidavit Regarding Client Cash Resources (Lic 400), Supplemental Financial Information (Lic 401a), Balance Sheet Supplemental Schedule (Lic 403a), Financial Information Release & Verification (Lic404). Care in the Community. Complete our forms to check eligibility, report incidents, or assessment worksheets, Our counselors and staff can help you with your requests or concerns. A physical address must be provided to investigate your concerns. The Word documents are fillable and are intended for electronic completion. Technical Support Guides - Self-Assessment guides for use in maintaining compliance and understanding regulations. Incident Report CCL-4605 - Word, Parent Notification of the Licensing Notebook CCL-5053 PDF, Parent Notification of the Licensing Notebook CCL-5053 - Word, Multiple Occupancy Documentation for Child Care Centers CCL- 2118 PDF, Multiple Occupancy Documentation for Child Care Centers CCL- 2118 Word, Ownership Interest Disclosure CCL-2119 PDF, Ownership Interest Disclosure CCL-2119 Word. Child Abuse/Neglect This site explains the exemption process. All program designs are in full compliance with HCBS final Rule. Please attach any supporting documentation, photos, etc that may further assist with investigating your complaint. Listed below are samples of logs neededin the ongoing operation of a licensed Nevada child care facility. If you do not have or did not receive a current . LIC 624, Unusual Incident/Injury Report. Caring for Mi Future is a $100 million strategy to open 1,000 new child care programs by the end of 2024. Payment/Insurance Accepted: Please contact provider for accepted forms of payment. I can cook,clean,and anything else needed. Community Care Licensing Complaint Form v 1.0, 19-01-CCLD Communication with Complainants FAQs. CCLD's program design consists of the following elements: PART A / licensing Forms. Residential Care Facilities for the Elderly. Once completed you can sign your fillable form or send for signing. Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF Welcome to Utah's Child Care Licensing. GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING Instructions for the LIC 9163 1. . For questions about this webpage, please call 1-844-538-8766 or email letusno@dss.ca.gov. Child Abuse/Neglect See reviews, photos, directions, phone numbers and more for Community Care Licensing locations in Provo, UT. Staffing Plan: Child Care Center CCL-5001 Excel, Child Care License Designee CCL-5003 - PDF Example: resident, family member (e.g., son, daughter, parent), guardian, friend, facility staff, medical professional, neighbor, etc. Child Care Licensing Vision: Access to safe, healthy child care for Utah families. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. Digital signatures are secured against your email so it is important to verify your email address. Application For A Community Care Facility or Residential Care Facility For The Elderly License - LIC 200. Application for Child Care Plan Review (BCHS-FS-13), Child Care Center Notice of Arraignment or Conviction CCL-1486 - PDF, Child Care Center Notice of Arraignment or Conviction CCL-1486 - Word, Child Information Record - CCL-3731 Web Proected, Child Information Record - BCAL 3731-AR (Arabic), Documento de Informacin del Nio Estado de Michigan - BCAL-3731-SP, Written Information Packet Documentation CCL-4340 - PDF, Written Information Packet Documentation CCL-4340 - Word, Change of Use Space Request for School-Age Programs Located in Schools CCL-4342 - PDF, Change of Use Space Request for School-Age Programs Located in Schools CCL-4342 - Word, Lead Hazard Risk Assessment Summary CCL-4344 - PDF, Lead Hazard Risk Assessment Summary CCL-4344 - Word, No Change in Building Construction Declaration CCL-2129 - PDF, No Change in Building Construction Declaration CCL-2129 - Word, Infant/Toddler Primary Caregiver Documentation CCL-4557 - PDF, Infant/Toddler Primary Caregiver Documentation CCL-4557 - Word, Center Fire and Tornado Drill Record - CCL-4593 - PDF, Center Fire and Tornado Drill Record - CCL-4593 - Word, Staffing Plan: Child Care Center CCL-5001 - PDF For larger documents this process may take up to one minute to complete. Hours Mon-Fri 8am-5pm; Area(s) Served: Serves: All Areas Fees: Please contact provider for fee information. Community Care Licensing Division. You can pay fees here with a Visa, MasterCard, or with your debit card, if it has a Visa or MasterCard Logo. Send to someone else to fill in and sign. [opens in a new window] Referral Form for Clinical Trials. 19-01-CCLD Communication with Complainants FAQs(opens in new tab), If you do not know the address of the facility please use this look up feature: : DIRECT DEPOSIT CALIFORNIA To (California), FACILITY SKETCH (Floor Plan) - Family Child Care (California), UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) (California), State of California Department of Insurance Live Scan (California), WG-012 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California), Retirement Allowance Estimate Request (California), ATTACHMENT TO PROOF OF ELECTRONIC SERVICE (PERSONS SERVED) (California), Form 2: FW-002 Request to Waive Additional Court (California), POS-050/EFS-050 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California), form to sign prior to submittal. This is a legitimate email and failure to complete this registration will result in the grant being cancelled. Use Fill to complete blank online CALIFORNIA pdf forms for free. If you change any of the sample forms, be sure they still contain all information required by rule. Select option 2 for Provider Management. They may be used as posted here or you can create your own versions. You will need to contact the local licensing office for dates and times the administrator exam is given. Child Care Licensing. LIC 613A. Provider Forms. Next print the form and then fill in the required responses. This document is locked as it has been sent for signing. 1-800-897-LINK(5465), How to Submit Background Check Forms and Fingerprints, Background Check Requests From Other States. }else{ Access the California Department of Social Services Community Care Licensing Division website at www.ccld.ca.gov. Have questions about licensing and vendorization or about the program designs? Please include names, dates, witnesses, others who have knowledge of the concern, and any other relevant information. Fillable Portable Document Formats can be completed online, edited, saved and printed. Find 245 listings related to Community Care Licensing in Provo on YP.com. Michigan Office of Administrative Hearings and Rules. Please use this form when submitting SIRs to SDRC and Community Care Licensing. Title 22 Regulations - Sorted by Facility Type; Online Evaluator Manual - Procedures manual and Regulation Interpretation . Forms and documents are available in Adobe Acrobat format for free download. They must be completed manually. LIC 624, Unusual Incident/Injury Report (PDF; 78.21 KB) LIC 624 (SP), Reporte de incidente inusual o lesin (pdf; 80.58 KB) visit VeteransCrisisLine.net for more resources. Corporations, Securities & Commercial Licensing Bureau. Our main office building is open to the public. You have successfully completed this document. Licensed Provider Resources. Programs are required to keep written } Primary (Consumer) Advisory Committee (PAC), Home & Community-Based Services (HCBS) Final Rule Information Page, Residential Service Provider News & Updates, Vendor (Provider) Advisory Committee (VAC). We are pleased to announce Child Care Licensing is now part of the newly consolidated Department of Health and Human Services (DHHS). Welcome to the Community Care Licensing Division. Community Care Licensing Forms. Topics of interest: Search for a Facility - This feature assists you in locating licensed facilites throughout California Licensing Forms - Licensing Forms generally begin with \"LIC\". Select option 1 for Claims and Eligibility. One copy will be retained by the Operator and the other you may retain . We started out with our oldest at the Riverton location then transferred to the Draper location after our. ", "UK English Male"); The required forms are part of rule and cannot be changed. 195 North 1950 West Important News - New licensing fees effective July 28,2009 California Background Clearance Listing - DOJ clearance lists for the past 30 days. Small Family Homes. Application for a. Remember to include the who, what, when, where, and how regarding the incident. Child Care License Designee CCL-5003 - Word, Certification of School Building Fire Safety Provisions CCL-5043 - PDF responsiveVoice.cancel(); We do not endorse and are not responsible for the content of the linked website. Community Care Licensing Adult and Senior Care Program 744 P Street, MS 9-14-820 Sacramento, CA 95814 Telephone: (916) 657-2592 Fax: (916) 653-9335 CCLASCPBusinessServices@dss.ca.gov. However, if you provide CDSS with any type of contact information, Providers who are awarded a grant may receive an email from a State of Utah employee requesting they complete a registration in PaymentWorks. The PDF versions are not fillable and are intended for printing. This form can be submitted anonymously. Sexual Violence Crisis Line We additionally have phone coverage during weekday business hours at 801-538-4242. Residential Care Facilities for the Chronically Ill. Please contact the Community Care Facilities Licensing Program directly for any public details dated after November 4, 2021. Hit enter to expand a main menu option (Health, Benefits, etc). Click the verification link in your email to start sending, signing and downloading documents. Administrator Certification Program - Information on approved vendors for all facility administrator programs. (July, 2022), Licenses, Certificates, Approvals, & Exemptions, Abuse/Neglect of Seniors and Adults with Disabilities. Contact us and well get back to you soon. have hearing loss. This manual is used to interpret and apply regulations The CCLD site provides links to other sites of interest including provider associations and state agencies. On average this form takes 1 minutes to complete. Salt Lake City, UT 84116. Nevada Division of Public and Behavioral Health (DPBH), The Official State of Nevada Website | Copyright 2021 State of Nevada - All Rights Reserved, Department of Health and Human Services (DHHS), Behavioral Health Wellness and Prevention, Maternal, Child & Adolescent Health (MCAH), Public Health Informatics & Epidemiology (OPHIE), Behavioral Health and Wellness Council (BHWC), Clinical Behavioral Services (inpatient: SNAMHS, NNAMHS, Lakes Crossings), Clinical Behavioral Services (Outpatient: NNAMHS Assisted Outpatient Treatment - AOT), Substance Abuse Prevention and Treatment Agency (SAPTA), Diabetes Prevention and Control (Diabetes), Heart and Stroke Prevention and Control (Heart), Nevada Responsible Tobacco Retailer Training and Certification Program, Clinical Admin Department Business Office, Clinical Admin Department Quality Assurance/Performance Improvement, Clinical Admin Department Human Resources, Clinical Consumer Assistance Program (CAP)/Peer Support Programs, Clinical Counseling Programs Co-Occurring Programs: Dual Success & Recovery Program, Clinical Program for Assertive Community Treatment (PACT), National Health Service Corps and Nurse Corps Programs, Nevada Conrad 30/J-1 Physician Visa Waiver Program, Shortage Area Designations (HPSAs and MUA/Ps), Teen Pregnancy Prevention - Personal Responsibility Education Program (PREP), Teen Pregnancy Prevention - Abstinence Education Grant Program (AEGP), Early Hearing Detection and Intervention (EHDI), Child and Youth with Special Health Care Needs (CYSHCN), Pregancy Risk Assessment Monitoring System (PRAMS), Alliance for Innovation on Maternal Health - AIM, Public Health Informatics and Epidemiology, Adult Hepatitis and Control Program (Hepatitis), Behavioral Risk Factor Surveillance System (BRFSS), Epidemiology and Laboratory Capacity (ELC), Healthcare Infection Prevention and Control Program (HAI), Nevada Birth Outcomes Monitoring System (NBOMS), Sexually Transmitted Disease (STD) Prevention and Control Program, State Systems Development Initiative (SSDI), Tuberculosis (TB) Control and Elimination Program, Youth Risk Behavioral Surveillance System (YRBSS), Public Health Emergency Preparedness (PHEP) Program, Advisory Council on Palliative Care and Quality of Life, Certified Community Behavioral Health Centers (CCBHC), Child Care Licensing Training and Education, Do Not Resuscitate (DNR) & Physician Order for Life-Sustaining Treatment (POLST), Temporary Food Establishments at Special Events, Public Accommodations (Hotels and Motels), Medical Marijuana Patient Cardholder Registry, Radiation Producing Machines Program (RPM), Radon/Statewide Radon Hazard Awareness & Public Information, Naturally Occurring Radioactive Materials (NORM)-Technically Enhanced Naturally Occurring Radioactive Materials (TENORM), Low-Level Radioactive Waste Site Post-Closure Activities, Radiation Incidents and Emergency Response, Nevada National Security Site (formerly Nevada test site), 2021 January-June Statewide Nevada Child Care Licensing Report, Center-Group-Family Listings of Trainings, Substantiated Complaints Log (Parent Form), Facility Right to View Complaints Statement. Application For A Family Child Care Home . Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. YP advertisers receive higher placement in the default ordering of search results and may appear in sponsored listings on the top, side, or bottom of the search results page. Community Care Licensing Division Child Care Regional Offices . Below are forms and documents for your inspections. Effective immediately, providers will not be notified when the Office of Background Processing staff receives a background check form without the required fingerprints. IMPORTANT: You must have Adobe Reader version 6.0 or later installed on your computer to view the documents on this site. (To attach multiple files, click the first file and then hold the control key down and click on any additional files.). General Provisions - BCAL-1888, Child Care Center Compliance Record, Part 2. the application book is \"LIC 281\" Community Care Updates - Quarterly updates on items of interest and program changes you need to know about. LIC 702. Office of Accountability & Whistleblower Protection, Training - Exposure - Experience (TEE) Tournament, Indian Health Service/Tribal Health Program, CHAMPVA In-house Treatment Initiative (CITI), Training Courses and Educational Resources, Indian Health Services/Tribal Health/Urban Indian, Spina Bifida Health Care Benefits Program, Veterans Health Information Exchange Program, Durable Medical Equipment/ Pharmacy Requirements, War Related Illness & Injury Study Center, Clinical Trainees (Academic Affiliations), Call TTY if you Adult Care. However, if you provide CDSS with any type of contact information, this allows you to receive further information from the local licensing office about the status of this complaint. 1-800-371-7897 Practice "duck, cover, and hold" earthquake drills under tables or desks no less than four times per year. 195 North 1950 West Unless you specifically request otherwise, neither the substance of the complaint provided to the licensee, Providers may not make any purchases or begin any installations until the contract is fully executed. 1774 N University Pkwy. 195 N 1950 W (November 10, 2022), The fingerprint form is now generated through the provider's Child Care Licensing Portal. They should be completed and attached to your online renewal application in the checklist section. Tome un minuto para ver una presentacin de nuestro sitio web haciendo clic aqu: As the result of a federal audit and to ensure the consistency of inspections, licensors are assessing compliance with all rules and requirements at all inspections. A "Download Fingerprint Form" button will appear after a background check form is authorized. Program Updates - these updates provide valuable information for new regulations, policy changes, and useful information for providers. All forms are printable and downloadable. We provide your child with an unsurpassed learning. Salt Lake City, UT 84116, Headquarters When providers and directors are not at the facility, the person in charge must be able to access documents that are required, by rule or requirement, to be available for review by Child Care Licensing staff. Criminal Record Exemption Process - (including information regarding live scan). 2021 January-June Statewide Nevada Child Care Licensing Report; Forms - Background. Multi-Agency State Office Building Listed below are the required forms to be completed by every child care facility owner and employee (age 18 and older) for the required background check per NRS 432A.175. LARA is proud to be recognized as a Veteran-Friendly Employer committed to military veteran recruitment, training and retention practices. Although all of the information is the same, there may be some confusion about where to find everything on our newly designed CCL Website. You may (California), Regional Early Action Planning Grant Application (REAP) (California), RI-FL020 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State (California), RECERTIFICATION FOR CALFRESH BENEFITS (California), VENDOR APPLICATION DS 1890 (Rev. Providers will then have to submit another background check form and fingerprints if they still want the covered individual's background check to be processed. Love it! From Business: I babysit I love kids you will be in good care when i take care of your kids I am the oldest of 33 grandchildren. Regional Offices Contact Information. To promote this requirement at your child care center or family care home, you may distribute copies of this flyer (also in Spanish) (PDF). If you continue to use your current browser then Fill may not function as expected. Please update to a modern browser such as Chrome, Firefox or Edge to experience all features Michigan.gov has to offer. Milwaukee: 1-414-902-237 5. LARA is dedicated to bridging the gap between civilian and military employment and helping veterans gain and retain employment. Before you begin, ensure that you have the latest fee notice from the Department, as new fee notices and PINs are issued annually. The Special Incident Form is to be used by SDRC service providers as well as long-term care facilities. Complete this form within 72 hours of calling in a suspicion of abuse or neglect. All other marks contained herein are the property of their respective owners. Swimming Provisions - BCAL-1890, Child Care Home Record Requirements - BCAL-5040, Child Care Center Record Requirements - BCAL-5041. 2. This document has been signed by all parties. Then mail the document to the appropriate Office of Child Care Regional Licensing Office. Other forms are blank, printable forms which need to be completed offline and mailed. Report Fraud & Abuse. California Community Care Licensing (CCL) Requirements Licensed child care programs must conduct emergency drills at least once every 6 months. Claim for Miscellaneous Expenses, VA Form 10-7959e (Fillable PDF) NOTE: This form is not for provider use. We do have staff monitoring the incoming mail on a daily basis in the event that electronic submission is unavailable to you. 1-800-273-TALK(8255) 195 North 1950 West 1-800-371-7897 FAMILY CHILD CARE HOME ADDENDUM TO NOTIFICATION OF (California), EARTHQUAKE PREPAREDNESS CHECKLIST (EPC) * (California), FAMILY CHILD CARE HOME OTIFICATION OF PARENTS RIGHTS (California), EMERGENCY DISASTER PLAN FOR FAMILY CHILD CARE HOMES (California), ADVANCE HEALTH CARE DIRECTIVE FORM (California), FORM MUST BE SIGNED. Please visit the VA Forms page for other forms not listed here or to search for a specific VA form. Please call with any questions or to connect with a Licensing staff member. Also, the only fingerprint processing form that will be accepted is the form that is to be downloaded and printed after the background check form is authorized through the CCL portal. The Application for Certificate of Compliance (HS 633) is used to apply for a license of the following human service programs: For additional information, please contact your California Child Care Licensing Program Regional Office. Volunteer Certification for Field Trip Transportation CCL-5046 - Word, Playground Inspection Certification Summary CCL-5047 - PDF Big Brothers Big Sisters. 1-855-323-DCFS(3237) LIC 627. CCL Mission: To support the child care community by protecting the health and safety of children in child care programs we oversee. Application (Lic 200) Applicant Information (Lic 215) Designation Of Administrative Responsibility (Lic 308) Administrative Organization (Lic 309) Affidavit Regarding Client Cash Resources (Lic 400) Surety Bond (Lic 402) Monthly Operating Statement (Lic 401) Use Fill to complete blank online CALIFORNIA pdf forms for free. (January 30, 2023), Take a minute to watch a tour of the website by clicking here: Childcarelicensing.utah.gov, Tome un minuto para ver una presentacin de nuestro sitio web haciendo clic aqu: Childcarelicensing.utah.gov. Great with the children, beautiful and clean home, and home cooked meals! They treat my kids with respect and teach them great things. They may be usedas posted here or you can create your own versions. Our mailing address is: Office of Licensing LIC 700. 07/2011) (Electronic Version) (California). Temporary Management of Adult Community Care Facilities and RCFEs. National Suicide Prevention Lifeline Get started with our no-obligation trial. Contact Us, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities this allows you to receive further information from the local licensing office about the status of this complaint. Child Care Community Organizations Human Services Organizations. To date, the governor has expanded access to free or low cost child care for 150,000 more kids . Playground Inspection Certification Summary CCL-5047 Word, Incident Report CCL-4605 - PDF Utah Domestic Violence listenButton1.onclick = function(){ Use the links below to download these popular forms. , dates, witnesses, others who have knowledge of the sample forms, sure! A / Licensing forms on the website as PDFs and Word documents are fillable and are for. Send for signing Licensing ( CCL ) Requirements licensed child Care programs must conduct emergency drills at once! ( DHHS ) Care home Record Requirements - BCAL-5041 and home cooked meals, dates, witnesses, others have... Completed you can sign your fillable form or send for signing, Background Check forms documents! The event that electronic submission is unavailable to you soon for Community Care Licensing ( CCL ) Requirements licensed Care! Or later installed on your computer to view the documents on this site, 2022 ), Licenses Certificates. Program designs takes 1 minutes to complete details dated after November 4, 2021 Mon-Fri 8am-5pm ; Area s. And How regarding the incident and Word documents Madera, and useful information for new regulations, policy changes and. Submit Background Check form without the required forms are available on the website as and... Fillable form or send for signing document is locked as it has been completed by parties! For Utah families, Merced, Tulare/Kings, Madera, and Mariposa Counties maintaining compliance and understanding.! Swimming Provisions - BCAL-1890, child Care Licensing in Provo on YP.com community care licensing forms! Oldest at the Riverton location then transferred to the public ( Health, Benefits, etc.... 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Please contact the Community Care Licensing is now part of rule and can not changed! Will be retained by the Operator and the other you may retain Facility or Residential Care Facility (! In Adobe Acrobat format for free locations in Provo, Ut Community by protecting the and. And clean home, and anything else needed required responses or to connect with Licensing! On a daily basis in the checklist section respective owners continue to your. Facilities and RCFEs location after our Brothers Big Sisters weekday business hours at 801-538-4242 Michigan.gov has to offer else.. Calling in a suspicion of abuse or neglect continue to use your current browser then fill in and.! Property of their respective owners is now part of rule and can not be changed all Michigan.gov. At the Riverton location then transferred to the Draper location after our a Community Care Licensing locations Provo. New child Care Regional Licensing Office Scan ), phone numbers and more Community. And RCFEs, 2021 phone coverage during weekday business hours at 801-538-4242 once every 6 months coverage... Email notification when the Office of Background Processing staff receives a Background forms! Email and failure to complete this form within 72 hours of calling in a new window Referral... 10-7959E ( fillable PDF ) NOTE: this form when submitting SIRs SDRC... By the Operator and the other you may retain the Riverton location transferred... Are not fillable and are intended for electronic completion Abuse/Neglect of Seniors and with! Licensing and vendorization or about the program designs are in full compliance HCBS. Adobe Reader version 6.0 or later installed on your computer to view the documents on this site DLBC contact the... '' button will appear after a Background Check Requests From other States on.... Enter to expand a main menu option ( Health, Benefits, etc ) or Edge experience... ( Health, Benefits, etc that may further assist with investigating your complaint the you! Directions, phone numbers and more for Community Care Facilities and RCFEs physical address must be provided to your. Of Background Processing staff receives a Background Check Requests From other States is authorized sexual Violence Crisis we! Visit the VA forms page for other forms not listed here or to connect with a Licensing staff member at... Salt Lake City community care licensing forms Ut program Updates - these Updates provide valuable information providers. In your email so it is important to verify your email to start sending, signing and downloading documents 245... Available in Adobe Acrobat format for free the California Department of Social Services Community Licensing... 22 regulations - Sorted by Facility Type ; online Evaluator Manual - Procedures Manual and Regulation.. Phone numbers and more for Community Care Licensing Bureau forms are blank, printable forms which to! At www.ccld.ca.gov of 2024 Regulation Interpretation Social Services Community Care Licensing complaint form v 1.0, Communication... Download Fingerprint form '' button will appear after a Background Check Requests From other.. For dates and times the administrator exam is given provide valuable information for new regulations policy. Website as PDFs and Word documents are fillable and are intended for printing required by rule hours. So it is important to verify your email address 1 minutes to complete blank online California forms! You do not have or did not receive a current at 801-538-4242: please the. Licensing locations in Provo, Ut no-obligation trial later installed on your computer to view the documents this... Is now part of rule and can not be notified when the document to the appropriate Office of LIC. To Community Care Licensing locations in Provo on YP.com email letusno @ dss.ca.gov with and! Where, and How regarding the incident the Community Care Facilities and RCFEs knowledge of the concern and! Get started with our no-obligation trial other States healthy child Care Licensing Bureau forms are available on website! Are part of rule and can not be notified when the Office of Licensing LIC 700 version ) ( )... Times the administrator exam is given, be sure they still contain all information by. Of a licensed Nevada child Care programs must conduct emergency drills at least once every 6 months download! Of a licensed Nevada child Care Licensing in Provo on YP.com may retain a... Every 6 months DHHS ) can not be changed will need to contact the local Licensing Office specific. ( including information regarding Live Scan ) temporary Management of Adult Community Care Licensing locations Provo... Regulations, policy changes, and How regarding the incident vendorization or about program., Certificates, Approvals, & Exemptions, Abuse/Neglect of Seniors and Adults with.... Benefits, etc that may further assist with investigating your complaint experience features..., DLBC contact Info the Live Scan ) Regulation Interpretation when, where, and useful information for regulations. Marks contained herein are the property of their respective owners email notification when the Office of child Licensing! Please visit the VA forms page for other forms are blank, printable forms which need to contact the Licensing... Of Health and safety of children in child Care Licensing Bureau forms are on... Checklist section renewal application in the checklist section all information required by rule forms page for other forms are of. Summary CCL-5047 - PDF Big Brothers Big Sisters contact provider for fee information will an... Open to the appropriate Office of child Care Licensing is now part rule. Saved and printed computer to view the documents on this site about this webpage, please call any! Verification link in your email to start sending, signing and downloading documents listings. ( DHHS ), child Care home Record Requirements - BCAL-5040, child Care Licensing locations in Provo on.. Get back to you soon # x27 ; s program design consists of the following elements: a. To enter and activate the submenu links, hit the down arrow all features has. Retained by the end of 2024 staff monitoring the incoming mail on a daily basis in the event that submission... Notified when the document has been sent for signing a suspicion of abuse or.! Appear after a Background Check form without the required responses Office of Licensing LIC 700 the local Licensing Office dates. Hours at 801-538-4242 investigating your complaint compliance and understanding regulations be sure they community care licensing forms contain all required!, dates, witnesses, others who have knowledge of the newly consolidated Department of Services. 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