The Lic 500 form is a personnel report used by the California Department of Social Services. It helps facilities maintain an up-to-date roster of staff, volunteers, and other adults residing on the premises. Accurate completion of this form is essential for compliance with state regulations.
To ensure your facility meets all requirements, fill out the form by clicking the button below.
The Lic 500 form plays a crucial role in maintaining the safety and compliance of facilities under the California Department of Social Services. This personnel report is designed to keep an up-to-date roster of all individuals associated with a facility, including staff, volunteers, and licensees. It ensures that all personnel undergo necessary criminal background checks, as mandated by state regulations. The form requires details such as the name, job title, and working hours of each staff member, along with the specific days they are on duty. Additionally, it includes a section for individuals exempt from these background checks, allowing the licensee or designated representative to affirm their status. Accurate reporting of personnel changes is essential, as it helps the licensing agency monitor compliance with health and safety standards. Facilities must submit the original form to the licensing agency while retaining a copy for their records. By adhering to these guidelines, facilities can promote a safe environment for both staff and residents.
How to Do a Background Check on Yourself - Read all instructions carefully to ensure your application reflects your true history.
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Da - Users must supply a detailed description of each item for clear identification.
When filling out and using the Lic 500 form, consider the following key takeaways:
STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERSONNEL REPORT
INSTRUCTIONS: This form is intended for keeping a current roster of all the facility personnel, other adults and licensees residing in the facility, including backup persons, volunteers and licensee if administrator/director. Show license/certificate number if applicable for specialized staff [e.g., Social Worker and other consultant(s)]. Show coverage for twenty-four hour supervision in residential facilities. Report any changes in personnel to the licensing agency as required by regulations. Send original to Licensing Agency and retain copy in facility file.
NAME OF FACILITY
FACILITY TYPE
FACILITY NUMBER
PREPARED BY
DATE
A.STAFF SUBJECT TO CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following staff members are subject to a criminal background check pursuant to Sections 1522, 1568.09, 1569.17 and 1596.871 of the Health and Safety Code. A California background clearance or a criminal record exemption shall be obtained prior to employment, residence or initial presence in the facility.
SPECIFY
NAME
JOB TITLE
DAYS AND HOURS ON DUTY
EMPL'D
DAYS
FROM
TO
Licensee/Administrator
LIC 500 (11/03) (PUBLIC)
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B.STAFF EXEMPT FROM CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following are believed exempt from criminal background check requirements pursuant to Sections 1522, 1568.09, 1569.17 and 1596.871 of the Health and Safety Code. The licensee or designated representative shall sign below to verify that he or she believes the indicated persons are exempt from criminal background check requirements pursuant to statute.
Signature ________________________________________________________________________________ Date __________________
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