%%EOF These reports are required of both family child care homes and centers. All information is provided in good faith, however, we make no representation or warranty of any kind regarding its accuracy, validity, reliability, or completeness. DATE . EMERGENCIES - LIFE THREATENING - Call 9-1-1 - Tell them: Number Calling from: 5. REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING Applicant Submission 1. ... health and human services agency california department of social services community care licensing division unusual incident/injury report instructions notify licensing agency placement agency and responsible persons if any by next working day. iii. personnel changes, contact information changes, and changes to the facility. A Small Family Child Care Home provides care Form LIC 624, Unusual Incident/Injury Report, also known as the LIC injury report form or the LIC unusual incident report form, is an application created for daycare providers that allows them to report unusual incidents and/or injuries to the appropriate California state agencies. This 1-hour course topic covers the general licensing requirements in completing a LIC 624 in residential facilities for both Adult Residential Facility and Residential Care Facility for the Elderly. Authorized Applicant Type - Enter from list on Page 2, “DOJ Abbreviated CCLD Facility Type.” 03502 ( ) The phone reports are made no later than the next working day after the event occurs. COMMUNITY CARE LICENSING DIVISION CRIMINAL RECORD STATEMENT State law requires that persons associated with licensed facilities or Home Care Aide Registry applicants be fingerprinted ... LIC 508 (7/15) REQUIRED FORM -- NO CHANGE PERMITTED PAGE 2 OF 2. LIC 624 (SP), Reporte de incidente inusual o lesión (pdf; 80.58 KB) Ordering Our Publications? Child Care Center Operators. PARENT’S SIGNATURE . retain copy of report in client’s file. telephone number ( ) address By the end of this course, participant will: Identify the proper documentation to use in filling out an incident report in a residential facility. instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. Sign up to receive e-mail updates on DPR's Licensing Program activities.. 425 0 obj <>stream Events involving a public health risk (e.g. Family Child Care is non-medical care and supervision forchildren, in the provider’s own home, for periods less than 24 hours. As child care providers, uphold the personal rights of each client in care facilities through … Download the document to your desktop, tablet or smartphone to be able to print it out in full. Community Care Licensing Division Welcome to the Community Care Licensing Division. instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. unusual incident/injury report . submit written report within 7 days of occurrence. SEX : BIRTH DATE : ... REASON FOR REQUESTING DAY CARE PLACEMENT . Download our form. NOTE TO PHYSICIAN: The person specified below is a resident/client of or an applicant for admission to a licensed Community Care Facility. Reports of any kind of criminal violation are to be filed to local law enforcement authorities. Learn more about how family child care homes and child care centers can protect and promote children’s health and safety. Community Care Licensing Representative 2: On the Licensing website you’ll find emergency disaster planning forms that must be completed as part of your license application. community care licensing division unusual incident/injury report instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. 2021 ©, Form LIC624 "Unusual Incident/Injury Report" - California, Rental Property Inspection Checklist for Landlords, USCIS Form I-551, Permanent Resident Card, Washington State Patrol Inspection Request Form, Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration, Form REG 124, Application for Assigned Vehicle Identification Number Plate, LIC 624B, Unusual Incident/Injury Report - Family Child Care Home, LIC 624-LE, Law Enforcement Contact Report, U.S. Department of the Treasury - Internal Revenue Service, Form LIC995a "Family Child Care Home Notification of Parents' Rights" - California, Form LIC624-LE "Law Enforcement Contact Report" - California, Form LIC624B "Unusual Incident/Injury Report - Family Child Care Home" - California, "Incident / Injury Report - the Texas a&m University System" - Texas, Form QR285B "CalFresh Budget Worksheet/Quarterly Reporting Households" - California, Form DHCS5079 "Unusual Incident/Injury/Death Report" - California, "Unusual Incident Monthly Report Log Form for Independent Providers", Form DFA285B "CalFresh Budget Worksheet/Change Reporting Household" - California, Form AD4315 "Recommendation of Dismissal of Petition Court Report Outline" - California, Form 79-072A "Daily Livestock Slaughter Report (Cattle)" - California, Form CDTFA-217 "Common Carrier's Report of Delivery" - California, Form CDTFA-1096 "Customs Broker's Report of Transactions" - California, Form DHCS3092 "Medi-Cal Supplemental Cost Report Schedules" - California, Form CEM-0101 "Resident Engineer's Report of Assignment" - California, Form CFS119-A "Unusual Incident Disposition Form" - Illinois, NJDMAVA Form 6 "Preliminary Unusual Incident - Sentinel Event Report" - New Jersey, Form PC324 (AR-800) "Quarterly Injury Report Amusement Ride Safety Inspection and Insurance Act" - Texas, Form S-41A "Incident/Injury Report Form" - Rhode Island, DCYF Form 15-454 "Unusual Incident Report" - Washington, Form DHCS_5079 "Unusual Incident/Injury/Death Report" - California, Form RW11-23 "Contractor's Time Reporting Sheet" - California, Form DBO-524 "Trust Company Consolidated Report of Income" - California, Identifying Number Value Worksheets With Answers Keys, Worksheets, Practice Sheets & Homework Sheets. submit written report within 7 days of occurrence. One type is unusual incidents. Keep current - Return a copy to the licensing office. facility file number . Welcome to your online resource for Community Care Licensing regulations and requirements. This health appraisal ... LIC 503 (ENG/SP) (3/99) PERSONAL. Form LIC 624, Unusual Incident/Injury Report, also known as the LIC injury report form or the LIC unusual incident report form, is an application created for daycare providers that allows them to report unusual incidents and/or injuries to the appropriate California state agencies. A licensed child care provider is required to submit current and accurate reports to Community Care Licensing in a timely fashion. 469 California Legal Forms And Templates are collected for any of your needs. community care licensing division unusual incident/injury report instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. get the free lic 624 form. Community Care Licensing Forms Lic 624 is not the form you're looking for? Complete Lic 624 online with US Legal Forms. aFamily Child Care Home license, and to gain access to andprint forms. Google Translate. There are two types of reports. LIC 9163 (12/15) - Request Live Scan Service - Community Care Licensing LIC 9163B (7/11) - Request For Live Scan Service - Long Term Care Ombudsman LIC 9165 (2/99) - Board Of Director Statement STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LIC 624-LE (4/16) PAGE3OF4 PART 2 CHECK THIS BOX IF ANY CHILD RESIDING IN THE FACILITY WAS … Consult with the appropriate professionals before taking any legal action. Reporting Requirement Title 22 regulation and a blank copy of form LIC 624; Unusual Incident/Injury Report. 15. COMMUNITY CARE LICENSING EMERGENCY DISASTER PLAN FOR FAMILY CHILD CARE HOMES Type or print clearly. submit written report within 7 days of occurrence. SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE. BRIEFLY DESCRIBE THE INJURY. Use this health and safety app of each child at day care to promote quality community care. Outbreaks of communicable diseases (e.g. STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY, NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND. Save or instantly send your ready documents. These plans require you to consider the following. Easily fill out PDF blank, edit, and sign them. GENERAL INSTRUCTIONS FOR COMPLETION 1. A detailed written report must be filed within 7 days of the event. community care licensing division death report licensee must report the death of a client of any cause, regardless of where the death occurred. COMMUNITY CARE LICENSING . LIC 624A Death Report Licensee Must Report the Death of a Client of Any Cause, Regardless Of Where The Death Occurred STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION This website includes videos that explain licensing topics relevant to families and licensed child care providers. gh#2000079-730-2. Title: LIC 508 7_15.PDF Author: CCHP is a program of the University of California San Francisco School of Nursing, Department of Family Health Care Nursing. Authorized Applicant Type - Enter from list on Page 2, “DOJ … Here are some examples: Legal Disclamer: The information provided on TemplateRoller.com is for general and educational purposes only and is not a substitute for professional advice. See reviews, photos, directions, phone numbers and more for State Of California Community Care Licensing locations in Fresno, CA. ;Î;¢5:Høï÷ôÛ£" —Pue÷/ ±}§¬(PĞ›â#8ş/%ŒŞ�Ο ‹FÅæı¸in_ŸX]e¼µúö@‚qî›X ÑXÕ 6âZnÉ¡C$°ñ²ë‡ı“2Œª­M,|(ãŠdo�ÆWmœE¼ßğ˜ŞØɽŠ°ÍÏã�Z-İPÀ‡OyÕäözø0åq�#ü€%¡Ày‰ôüm½ït˜+Ïd–Ç. Personnel changes reports are made within 10 days of the change. Some events must be reported not only to the Community Care Licensing, but to more than one government agency. Licensing Forms. DESCRIBE WHAT HAPPENED. Video instructions and help with filling out and completing lic 624. Unusual incidents (LIC 624 for child care centers and LIC 624B for family child care homes) is one type of such reports. PERSON(S) WHO OBSERVED THE INCIDENT/INJURY: EXPLAIN WHAT IMMEDIATE ACTION WAS TAKEN (INCLUDE PERSONS CONTACTED): ACTION TAKEN OR PLANNED (BY WHOM AND ANTICIPATED RESULTS: AGENCIES/INDIVIDUALS NOTIFIED (SPECIFY NAME AND TELEPHONE NUMBER), LICENSING______________________________________, ADULT/CHILD PROTECTIVE SERVICES________________________, LONG TERM CARE OMBUDSMAN___________________, PARENT/GUARDIAN/CONSERVATOR__________________________, LAW ENFORCEMENT_____________________________, PLACEMENT AGENCY______________________________________, TemplateRoller. community care licensing division . facility exit locations (using a copy of the facility sketch [lic 999] indicate exits by number) state of california - health and human services agency california department of social services emergency disaster plan for child care centers instructions: post a copy in a … Enter the current month, day, and year. Comments and Help with california licensing form lic 624. Search. mumps or measles); Suspected child abuse or any incidents that put children in danger, may it be their wandering away from the facility unattended or injuries requiring medical intervention. Post next to phone. Find 4 listings related to State Of California Community Care Licensing in Fresno on YP.com. This app includes all the detailed information necessary to complete form LIC 624. nasw #886756920. rcfe #2000079-740-2. strtp #2000079-733-2. rcfe ictp #2000079-740-1 View, download and print Lic 624 - Unusual Incident/injury Report pdf template or form online. LIC 624B (6/03) SEE INSTRUCTIONS ON REVERSE 16. submit written report within 7 days of occurrence. A license may be issued for a Small Family Child Care Home or a Large Family Child Care Home. Watch these brief, informative videos to learn more about putting Licensing requirements into practice. cna nac#7050. CHILD’S NAME . We serve the most vulnerable people of California and our mission is to promote the health, safety, and quality of life of each person in community care through the administration of an effective and collaborative regulatory enforcement system. All rights reserved. State Child Care Licensing County Child Care Licensing Child Protective Services Law Enforcement. REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING Applicant Submission 1. nha #cep1619. outbreak of a communicable disease) are to be reported to the Department of Public Health. DESCRIBE EVENT OR INCIDENT (INCLUDE DATE, TIME, LOCATION, PERPETRATOR, NATURE OF INCIDENT, ANY ANTECEDENTS LEADING UP TO INCIDENT AND HOW CLIENTS WERE AFFECTED, INCLUDING. name of facility . [The report appears: form LIC 624B for family child care homes and LIC 624 for child care centers.] Below are some examples of unusual incidents to be reported: The other type of report relates to the facility operation, e.g. Pressing the PRINT button will only print the current page. Unusual incident reports, thanks to their nature, are filed by phone and in writing. ORI: A0448 CA Dept of Social Services PO BOX 944243 Sacramento, CA 94244-2430 LIC 9163 (10/15) PAGE 1 OF 4 3. 0 COMMUNITY CARE LICENSING PHYSICIAN’S REPORT FOR COMMUNITY CARE FACILITIES For Resident/Client Of, Or Applicants For Admission To, Community Care Facilities (CCF). CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT . Community Care Licensing Representative 2: ... [Licensing form LIC 311D appears—“Forms and Records to Keep in Your Family Child Care Home.”] And after a child leaves your care, the signed portion of the notification of parents’ rights must be kept on file for 3 years. endstream endobj startxref cdss vendor: arf #2000079-735-2. brn #cep16081. Search for another form here. Application and renewal packets. These reports are mandatory for both family child care homes and centers. To Community care Licensing Applicant Submission 1 Author: Licensing Forms LIC for! Department of family health care Nursing DOJ … Complete LIC 624 placement agency and responsible persons, any. Licensing Forms Type - enter from list on Page 2, “ …... History—Parent ’ s report Licensing child Protective Services Law Enforcement for a family. Copy of report in client ’ s file welcome to your desktop, tablet or smartphone be..., directions, phone numbers and more for state of California Community Licensing. 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