ORI: A0448 CA Dept of Social Services PO BOX 944243 Sacramento, CA 94244-2430 LIC 9163 (10/15) PAGE 1 OF 4 3. 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 … 2. 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. NOTE TO PHYSICIAN: The person specified below is a resident/client of or an applicant for admission to a licensed Community Care Facility. ±~‚ˆZ ‘6‘�‰‘ñ=ÈŒ£ÕˆÿLg÷ î6] 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 See reviews, photos, directions, phone numbers and more for State Of California Community Care Licensing locations in Fresno, CA. LIC 624B (6/03) SEE INSTRUCTIONS ON REVERSE 16. 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. outbreak of a communicable disease) are to be reported to the Department of Public Health. instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. Google Translate. Learn more about how family child care homes and child care centers can protect and promote children’s health and safety. 469 California Legal Forms And Templates are collected for any of your needs. COMMUNITY CARE LICENSING PHYSICIAN’S REPORT FOR COMMUNITY CARE FACILITIES For Resident/Client Of, Or Applicants For Admission To, Community Care Facilities (CCF). CCHP is a program of the University of California San Francisco School of Nursing, Department of Family Health Care Nursing. 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. GENERAL INSTRUCTIONS FOR COMPLETION 1. BRIEFLY DESCRIBE THE INJURY. DESCRIBE EVENT OR INCIDENT (INCLUDE DATE, TIME, LOCATION, PERPETRATOR, NATURE OF INCIDENT, ANY ANTECEDENTS LEADING UP TO INCIDENT AND HOW CLIENTS WERE AFFECTED, INCLUDING. Licensing Forms. nasw #886756920. rcfe #2000079-740-2. strtp #2000079-733-2. rcfe ictp #2000079-740-1 Download our form. community care licensing division . DESCRIBE WHAT HAPPENED. One type is unusual incidents. View, download and print Lic 624 - Unusual Incident/injury Report pdf template or form online. PARENT’S SIGNATURE . 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. 0 LIC 624 (SP), Reporte de incidente inusual o lesión (pdf; 80.58 KB) Ordering Our Publications? Watch these brief, informative videos to learn more about putting Licensing requirements into practice. get the free lic 624 form. All rights reserved. cna nac#7050. name of facility . Use this health and safety app of each child at day care to promote quality community care. These reports are mandatory for both family child care homes and centers. %%EOF The complete packets include the application and other required forms, fact sheet on licensing or certification requirements, suggested study materials, exam schedule, and Visa/Mastercard transaction form. All information is provided in good faith, however, we make no representation or warranty of any kind regarding its accuracy, validity, reliability, or completeness. These plans require you to consider the following. retain copy of report in client’s file. Comments and Help with california licensing form lic 624. Community Care Licensing Forms Lic 624 is not the form you're looking for? Family Child Care is non-medical care and supervision forchildren, in the provider’s own home, for periods less than 24 hours. Find 4 listings related to State Of California Community Care Licensing in Fresno on YP.com. Authorized Applicant Type - Enter from list on Page 2, “DOJ … The phone reports are made no later than the next working day after the event occurs. 15. Download the document to your desktop, tablet or smartphone to be able to print it out in full. SEX : BIRTH DATE : ... REASON FOR REQUESTING DAY CARE PLACEMENT . nha #cep1619. Unusual incidents (LIC 624 for child care centers and LIC 624B for family child care homes) is one type of such reports. CHILD’S NAME . RESPONSIBLE PERSONS, IF ANY, BY NEXT WORKING DAY. A Small Family Child Care Home provides care Application and renewal packets. As child care providers, uphold the personal rights of each client in care facilities through … submit written report within 7 days of occurrence. REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING Applicant Submission 1. CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT . Welcome to your online resource for Community Care Licensing regulations and requirements. community care licensing division unusual incident/injury report instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. Post next to phone. COMMUNITY CARE LICENSING HEALTH SCREENING REPORT – FACILITY PERSONNEL All ... or employed staff of Residential Care Facilities for the Elderly, Community Care or Child Care facilities must demonstrate that their health condition allows them to perform the type of work required. And suspected child abuse cases must also be reported to a child protective agency. telephone number ( ) address There are two types of reports. SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE. These reports are required of both family child care homes and centers. Title: LIC 508 7_15.PDF Author: COMMUNITY CARE LICENSING EMERGENCY DISASTER PLAN FOR FAMILY CHILD CARE HOMES Type or print clearly. Events involving a public health risk (e.g. A licensed child care provider is required to submit current and accurate reports to Community Care Licensing in a timely fashion. Personnel changes reports are made within 10 days of the change. Enter the current month, day, and year. DATE . submit written report within 7 days of occurrence. This app includes all the detailed information necessary to complete form LIC 624. 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. retain copy of report in client’s file. endstream endobj startxref 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. ORI: A0448 CA Dept of Social Services PO BOX 944243 Sacramento, CA 94244-2430 LIC 9163 (3/11) PAGE 1 OF 4 3. 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. A license may be issued for a Small Family Child Care Home or a Large Family Child Care Home. COMMUNITY CARE LICENSING . 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. ... 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. Community Care Licensing Division Welcome to the Community Care Licensing Division. EMERGENCIES - LIFE THREATENING - Call 9-1-1 - Tell them: Number Calling from: 5. Search for another form here. Authorized Applicant Type - Enter from list on Page 2, “DOJ Abbreviated CCLD Facility Type.” 03502 ( ) A detailed written report must be filed within 7 days of the event. Sign up to receive e-mail updates on DPR's Licensing Program activities.. Child Care Center Operators. Reports of any kind of criminal violation are to be filed to local law enforcement authorities. This website includes videos that explain licensing topics relevant to families and licensed child care providers. Some events must be reported not only to the Community Care Licensing, but to more than one government agency. submit written report within 7 days of occurrence. gh#2000079-730-2. 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. Pressing the PRINT button will only print the current page. LICENSEE NAME: 1. By the end of this course, participant will: Identify the proper documentation to use in filling out an incident report in a residential facility. 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 facility file number . ;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. Search. Reporting Requirement Title 22 regulation and a blank copy of form LIC 624; Unusual Incident/Injury Report. Below are some examples of unusual incidents to be reported: The other type of report relates to the facility operation, e.g. Community Care Licensing. 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. community care licensing division unusual incident/injury report instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. Back to Licensing and Certification Program. Unusual incident reports, thanks to their nature, are filed by phone and in writing. iii. Outbreaks of communicable diseases (e.g. retain copy of report in client’s file. community care licensing division death report licensee must report the death of a client of any cause, regardless of where the death occurred. submit written report within 7 days of occurrence. aFamily Child Care Home license, and to gain access to andprint forms. Keep current - Return a copy to the licensing office. HC CCL 62 - Licensing Procedures for New Child Care Facilities - Español HC CCL 92 - School Age Child Care Licensing Application Form - English HC CCL 99 - School Readiness Provider Application - English Know Your Child Care Facility Brochure - English Family Child Care Homes Forms [The report appears: form LIC 624B for family child care homes and LIC 624 for child care centers.] LIC 624 Form was released by the California Department of Social Services Community Care Licensing Division on April 1, 1999, and can be downloaded from the link below. 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. TemplateRoller.com will not be liable for loss or damage of any kind incurred as a result of using the information provided on the site. 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 … REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING Applicant Submission 1. Easily fill out PDF blank, edit, and sign them. Consult with the appropriate professionals before taking any legal action. Operators of licensed child care centers have an important role in protecting the health and safety of children. unusual incident/injury report . STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY, NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND. retain copy of report in client’s file. personnel changes, contact information changes, and changes to the facility. This health appraisal ... LIC 503 (ENG/SP) (3/99) PERSONAL. 425 0 obj <>stream cdss vendor: arf #2000079-735-2. brn #cep16081. Save or instantly send your ready documents. Video instructions and help with filling out and completing lic 624. Complete Lic 624 online with US Legal Forms. State Child Care Licensing County Child Care Licensing Child Protective Services Law Enforcement. After the event occurs 7_15.PDF Author: Licensing Forms admission to a licensed Community care Licensing death. And accurate reports to Community care Licensing in a timely fashion, Department family... Current month, day, and to gain access to andprint Forms accurate reports to care! Instructions and Help with California Licensing form LIC 624 is not the form you 're looking?. 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