2015 Statewide Annual Nevada Child Care Licensing Report Forms - Background 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. COMMUNITY CARE LICENSING DIVISION CHILD CARE OFFICES Program Administrator, Shanice Orum 744 P Street, MS: T9-15-48 Sacramento, CA 95814 (916) 651-6040 FAX (916) 651-0531 NORTHERN CHILD CARE AREA OFFICE Assistant Program Administrator, Robert Garza 744 P Street, MS T9-15-48 Sacramento, CA 95814 (916) 651-6040 FAX (916) 651-0531 CHICO REGIONAL OFFICE Regional … 744 P Street, MS 8-17-17 A licensee must ensure the health, safety and well-being of children being cared for in his/her facility, and comply with the requirements of the Act, Regulation and Standards of Practice.As a licensed care provider you are required to review and become familiar with the legislation. Fraser Health . Legal. Programs Behavioral Health - Inpatient Services Behavioral Health Wellness and Prevention Chronic Diseases Clinical Services Community Services Health Planning & Primary Care Immunizations Maternal, Child & Adolescent Health (MCAH) Oral Health Public Health Informatics & Epidemiology (OPHIE) Public Health Preparedness Suicide Prevention Food Security Vital Records Women, Infants & … Make individual files for each child and each staff member. Community care licensing; Child care providers Child care providers. Problems with downloading forms? With members living throughout Southeastern Wisconsin, we count on you to help us provide the very best in care. Click on the category to ... HC CCL 92 - School Age Child Care Licensing Application Form - English HC CCL 99 - School Readiness Provider Application - English The director of licensing is appointed by the minister as the steward for all Health Authority Community Care Licensing Programs. This plan will talk about the things that are important to you and the goals you have for yourself. Copyright © 2021 California Department of Social Services, Assembly Bill 388 Report of Law Enforcement, Self-Assessment Guides and Key Indicator Tools. This guidance is aimed at home and community health care providers who provide in-person (i.e., one-on-one) services. License. Facilities with Available Beds from 6Beds, Inc. Community Care Licensing Division To enter the site, login below using the Facility Number and PIN from the upper right corner of your bill. The Community Care Facilities Licensing program works collaboratively with licensees and facility personnel to ensure the Community Care and Assisted Living Act , Child Care Licensing Regulation and Residential Care Regulation are met within the Island Health region. For inspections in ... Child Care GI Outbreak Surveillance Form. Back to Licensing and Certification Program. Who to Contact. HEALTH AND HUMAN SERVICES AGENCY . Community Care Licensing Division Welcome to the Community Care Licensing Division. 2015 Statewide Annual Nevada Child Care Licensing Report Child Care Licensing Forms & Publications. Problems with downloading forms? To file a complaint regarding a state licensed community care facility or child care facility visit our Complaint Hotline Page for contact information and more. Click here: Tips for Using Adobe PDF Files. There are many forms and publications to help child care providers run a child care business in Wisconsin. Reg. Reviews (805) 562-0400. Long Term Care and Community Support Program; Medical Care Plan (MCP) Prescription Drug Program (NLPDP) Mental Health Care and Treatment Act; Healthcare Providers; Medical Assistance in Dying; Health Promotions and Wellness; Note: all links below are PDFs and will open in a new window. Operators of licensed child care centers have an important role in protecting the health and safety of children. Tips for Using Adobe PDF Files, Copyright © 2021 California Department of Social Services, ICPC 100A Instructions (7/20) – Instructions For Completing Form ICPC — 100A Interstate Compact On The Placement Of Children Request, ICPC 100A (11/20) –Interstate Compact On The Placement Of Children Request, ICPC 100B Instructions (7/20) – Instructions For Completing Form ICPC — 100B Interstate Compact Report On Child’s Placement Status, ICPC 100B (7/20) – Interstate Compact On The Placement Of Children Report On Child’s Placement Status, IHSS-E 002 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Provider For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances, IHSS-E 003 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances, IHSS-E 004 (4/17) - In-Home Supportive Services Program Notice Of Non-Receipt Of Exemption From Workweek Limits Provider Agreement (APD 006), IHSS-E 005 (1/17) - In-Home Supportive Services Program Notice Of Ineligibility To Request Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) - Provider, IHSS-E 006 (4/17) - In-Home Supportive Services Program Notice To Provider Of Expiration Of Exemption From Workweek Limits, IHSS-E 007 (4/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Provider’s Expiration Of Exemption From Workweek Limits, KG 1 (12/11) - Kin-GAP Mutual Agreement For 18 Year Olds, KG 2 (1/11) - Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (Kin-GAP) Program, KG 3 (12/11) - Kin-GAP Mutual Agreement For Nonminor Former Dependents, KG 4 (2/14) - Kinship Guardianship Assistance Payment (Kin-GAP) Program - Nonrecurring Legal Guardianship Expenses Agreement, KG 5 (2/14) - Kinship Guardianship Assistance Payments (Kin-GAP) Program Nonrecurring Legal Guardianship Expenses Form, LIC 00 (8/17) - Conversion to Resource Family: Release of Information, LIC 00A (2/17) - Conversion - Resource Family Application, LIC 01A (7/19) - Resource Family Application, LIC 01C (7/16) - Resource Family Application-Confidential, LIC 03 (7/19) - Resource Family Home Health And Safety Assessment Checklist Document For Agency Use Only, LIC 05A (8/19) - Resource Family Approval Certificate, LIC 12 (9/19) - Resource Family Approval Document Alternative Plan (DAP), LIC 102 (9/99) - Sanitation Inspection Request, LIC 107 (9/00) - Applicant Fingerprint Follow-Up Request, LIC 165 (8/07) - Board Of Directors Statement, LIC 178 (12/15) - Deficiency/Penalty Review, LIC 184 (5/00) - Notification Of Incomplete Application, LIC 184A (1/08) - Notification Of Incomplete Foster Family Home Application, LIC 184B (1/14) - Notification Of Incomplete Application - Family Child Care Home, LIC 184C (1/14) - Notification Of Incomplete Application (NOIA) Child Care Centers - Pre-30-Day NOIA, LIC 184D (1/14) - Notification Of Incomplete Application (NOIA) Child Care Centers - 30-Day NOIA, LIC 184E (8/19) - Notice Of Incomplete Application (NOIA) Changes To Corporate Status, LIC 186A (10/04) - Orientation Meeting Family Child Care Home, LIC 192 (7/03) - Notification Of Initial Application Denial, LIC 195 (8/19) - Notice Of Operation In Violation Of Law, LIC 195A (8/19) - Notice Of Operation In Violation Of Law - Family Child Care Home, LIC 198 (2/01) - Child Abuse Central Index Check For County Licensed Facilities, LIC 198B (3/20) - Out-Of-State Child Abuse/Neglect Report Request, LIC 200 (2/11) - Application For A Community Care Facility or Residential Care Facility For The Elderly License, LIC 200TM (6/18) - Temporary Manager Application For Provisional License, LIC 200A (2/17) - Application for a Child Care Center License, LIC 201F (2/01) - Annual License Fee Notice - County, LIC 215TM (11/18) - Temporary Manager Candidate List Application Information, LIC 216TM (11/18) - Temporary Manager Appointment Applicant Information, LIC 229 (9/99) - Certificate Of Approval (For Certified Family Homes), LIC 279 (2/09) - Application For A Family Child Care Home License, LIC 279A (5/17) - License Application And Instructions For Family Child Care Homes, LIC 279B (10/05) - Current Children In Your Home - Application For A Family Child Care Home License, LIC 281 (9/04) - Application Instructions for A Facility License, LIC 281A (1/07) - License Application And Instructions For Child Care Centers, LIC 281D (1/17) - Application And Supporting Documentation Checklist Foster Family Agency, LIC 281E (1/17) Application And Supporting documentation Checklist Short - Term Residential Therapeutic Program, LIC 282 (8/08) - Affidavit Regarding Liability Insurance For Family Child Care Home, LIC 283 (4/10) - Foster Family Home Application, LIC 283A (12/07) - Foster Family Home Application Instructions, LIC 300A (9/03) - Removal Confirmation - Exemption Needed, LIC 300B (9/03) - Removal Confirmation - Denial, LIC 300C (9/03) – Removal Confirmation – Rescinded, LIC 300D (9/03) - Removal Confirmation – Non-Exemptible, LIC 300E (12/03) - Removal Confirmation - County, LIC 301A (8/07) - Reference Request - Adoption Facilitator, LIC 301B (8/07) - Reference Request - Long-Term Care Ombudsman Program, LIC 301E (7/03) - Reference Request - Exemption, LIC 306 (3/01) - Reporting Requirements By Licensees To The State Department Of Social Services, LIC 308 (11/02) - Designation Of Facility Responsibility, LIC 309 (6/01) (PUBLIC) - Administrative Organization, LIC 311A (3/07) - Records To Be Maintained At The Facility - Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children, LIC 311B (4/05) - Records To Be Maintained By The Facility - Group Homes, LIC 311C (4/05) - Records To Be Maintained At The Facility - Adult Residential, LIC 311D (3/07) - Forms/Records To Keep In Your Family Child Care Home, LIC 311E (4/05) - Records To Be Maintained At The Facility - Small Family Home And Foster Family Home, LIC 311F (4/05) - Records To Be Maintained At The Facility - Residential Care Facility For The Elderly, LIC 313 (12/01) - Evidence Of Program Consultant, LIC 400 (1/99) - Affidavit Regarding Client/Resident Cash Resources, LIC 401 (3/01) - Monthly Operating Statement, LIC 401A (3/99) - Supplemental Financial Information, LIC 403A (9/11) - Balance Sheet Supplemental Schedule, LIC 404 (7/99) - Financial Information Release And Verification, LIC 405 (8/01) - Record Of Client's/Resident's Safeguarded Cash Resources, LIC 406 (5/13) - Client/Resident Cash Sheet, LIC 421A (7/11) - Civil Penalty Assessment (Unlicensed Facility), LIC 421BG (5/19) - Civil Penalty Assessment – Caregiver Background Check, LIC 421CC (8/17) - Civil Penalty Assessment – Child Care, LIC 421D(ASC) (6/17) - Civil Penalty Assessment – Death/Serious Bodily Injury/Physical Abuse (ASC), LIC 421D(CC) (6/17) - Civil Penalty Assessment – Death/Serious Injury/Physical Abuse (Child Care), LIC 421D(CRP) (6/17) - Civil Penalty Assessment – Death/Serious Bodily Injury/Physical Abuse (CRP), LIC 421FC (7/17) - Civil Penalty Assessment – Failure To Correct And Repeat Violations, LIC 421IM (7/17) - Civil Penalty Assessment – Immediate $500 And Repeat Violations, LIC 422 (9/11) - Notice Of Civil Penalties Due, LIC 424 (1/03) - Record Of Client's Cash Resources For Change Of Licensee, LIC 503 (3/99) - Health Screening Report - Facility Personnel, LIC 507 (1/00) - Facilities Staff Work Schedule, LIC 508 (7/20) - Criminal Record Statement & Out-Of-State Disclosure, LIC 508 O-O-S (2/20) - Out-Of-State Disclosure, LIC 508A (3/11) - Criminal Record Statement - Adoption Facilitator, LIC 508B (3/11) - Criminal Record Statement - Long-Term Care Ombudsman Program, LIC 508D (8/17) - Out-Of-State Disclosure And Criminal Record Statement, LIC 601 (8/08) - Identification And Emergency Information, LIC 602 (7/11) - Physician's Report For Community Care Facilities, LIC 602A (8/11) - Physician's Report For Residential Care Facilities For The Elderly (RCFE), LIC 603 (9/99) - Preplacement Appraisal Information, LIC 604 (10/05) - Admission Agreement Guide For Residential Facilities, LIC 604A (2/05) - Admission Agreement For Residential Care Facilities For The Elderly, LIC 605A (5/00) - Release Of Client/Resident Medical Information, LIC 606 (8/18) - Residential Care Facility For The Elderly Disclosure Worksheet, LIC 610 (10/03) - Emergency Disaster Plan For Child Care Centers, LIC 610A (6/05) - Emergency Disaster Plan For Family Child Care Homes, LIC 610B (6/02) - Emergency Plan For Foster Family Homes, LIC 610C (10/03) - Emergency Disaster Plan For Children's Residential Facilities (Except Foster Family Homes), LIC 610D (10/03) - Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities, LIC 610E (3/19) - Emergency Disaster Plan For Residential Care Facilities For The Elderly, LIC 613 (12/02) - Personal Rights Adult Residential Care Facilities, LIC 613A (8/08) - Personal Rights - Child Care Centers, LIC 613B (9/19) - Personal Rights Children’s Residential Facilities, LIC 613C (1/19) - Personal Rights Of Residents In Publicly Operated Residential Care Facilities For The Elderly, LIC 613C-2 (1/19) - Personal Rights Of Residents In Privately Operated Residential Care Facilities For The Elderly, LIC 621 (4/99) - Client/Resident Personal Property And Valuables, LIC 622 (9/19) - Centrally Stored Medication And Destruction Record, LIC 622A (6/17) - Medication Administration Record (MAR), LIC 622B (5/17) - Psychotropic Medication Administration Record (MAR), LIC 623 (5/01) - Group Planned Activities, LIC 624 (4/99) - Unusual Incident/Injury Report, LIC 624B (8/08) - Unusual Incident/Injury Report - Family Child Care Home, LIC 624 LE (4/17) - Law Enforcement Contact Report, LIC 625 (11/19) – Appraisal/Needs and Services Plan, LIC 627 (9/08) - Consent For Emergency Medical Treatment - Child Care Centers Or Family Child Care Homes, LIC 627A (9/08) - Consent To A Medical Examination, LIC 627B (9/08) - Consent For Emergency Medical Treatment - Children's Residential Facilities, LIC 627C (4/00) - Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities, LIC 700 (10/19) - Identification And Emergency Information Child Care Centers/Family Child Care Homes, LIC 701 (8/08) - Physician's Report - Child Care Centers, LIC 701A (9/00) - Gastrostomy - Tube Care: Physician's Checklist (Child Care Facilities), LIC 701B (9/00) - Gastrostomy - Tube Care Consent/Verification (Child Care Facilities), LIC 702 (10/19) - Child's Preadmission Health History - Parent/Authorized Representative Report, LIC 808 (12/20) – Plan For Epidemic Outbreak Specific to COVID – 19 Mitigation Plan Report, LIC 809 (12/15) - Facility Evaluation Report, LIC 812 (8/06) - Detail Supportive Information, LIC 813 (11/99) - Facility Photography Report, LIC 857 (8/06) - Children's Record Review, LIC 858 (10/99) - Client/Resident Records Review, LIC 858A (7/00) - Additional Child Records Review For Specialized Foster Care Homes, LIC 859 (8/06) - Review of Staff/Volunteer, LIC 860C (12/02) - Facility Review Index Foster Family Homes, LIC 861 (1/03) - Prelicensing In-Home Interview, LIC 907 (5/00) - Transmittal For Processing, LIC 972 (5/00) - Individual Waiver/Exception Log, LIC 973 (4/03) - Documented Alternative Plan - Foster Family Homes (Bedrooms), LIC 974 (4/03) - Documented Alternative Plan - Foster Family Homes (Telephones), LIC 986A (10/99) - Notice Of Revocation Action, LIC 989A (3/17) - Non-Confidential Records Request Form, LIC 995 (9/08) - Child Care Center - Notification Of Parents' Rights, LIC 995A (8/08) - Family Child Care Home - Notification Of Parents' Rights, LIC 995B (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Removal/Exclusion), LIC 995C (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Reinstatement), LIC 995D (5/03) - Family Child Care Home Explanation Of Removal/Exclusions And Reinstatement, LIC 995E (10/09) - Important Information For Parents, LIC 995F (10/09) - Caregiver Background Check Information, LIC 996 (5/99) - Agreement For Licensure Of Community Care Facility/Child Care Facility On Federal Property, LIC 996A (5/01) - Agreement For Licensure Of Community Care Facility/Child Care Facility On Indian Reservations, LIC 997 (10/99) - Agreement By Licensee/Applicant On Federal Property, LIC 997A (4/01) - Agreement By Licensee/Applicant On Indian Reservations, LIC 999 (3/99) - Facility Sketch (Floor Plan), LIC 999A (2/05) - Facility Sketch (Floor Plan) - Family Child Care Home, LIC 9011A (4/05) - County Licensing Administrative Action Personnel Flagging Attachment, LIC 9011B (5/05) - CDSS Licensing Administrative Action Personnel Flagging Attachment, LIC 9020 (5/17) - Register Of Facility Clients/Residents, LIC 9020A (6/17) - Register Of Facility Residents - Residential Care Facilities For The Elderly, LIC 9029A (1/08) - Statement Of Facts Summary Sheet, LIC 9029B (7/09) - Statement Of Facts Preparation Checklist, LIC 9031 (11/99) - Notice Of Temporary Suspension Order Of License, LIC 9040 (10/05) - Child Care Facility Roster, LIC 9054 (3/99) - Local Fire Inspection Authority Information, LIC 9058 (12/15) - Applicant/Licensee Rights, LIC 9059 (5/99) - Personal Property Procedures, LIC 9060 (2/00) - Resident Theft And Loss Record, LIC 9092 (2/11) - Fire Pre-Inspection/Consultation Request, LIC 9095 (6/99) - Evaluation Of Teacher Qualifications, LIC 9096 (2/00) - Evaluation Of Director Qualifications, LIC 9099 (12/16) - Complaint Investigation Report, LIC 9102TA (2/19) - Advisory Notes - Technical Assistance, LIC 9102TV (2/19) - Advisory Notes - Technical Violation, LIC 9106 (11/19) - Group Home Program Statement General Instructions, LIC 9108 (3/05) - Statement Acknowledging Requirement To Report Suspected Child Abuse, LIC 9111 (12/99) - Noncompliance Conference Summary, LIC 9112 (9/20) - Facility Compliance Plan, LIC 9118 (11/03) - Facility Visit Checklist Child Care Centers And Infant Centers, LIC 9119 (7/20) – Facility Inspection Group Homes, LIC 9120A (2/20) - Licensed Facility Inspection Checklist Adult Care Facilities, LIC 9121 (11/03) - Facility Visit Checklist Family Child Care, LIC 9122 (11/03) - Facility Visit Checklist Foster Family Home, LIC 9122A (7/20) – Facility Inspection Checklist Small Family Home, LIC 9123 (2/20) - Facility Inspection Checklist - Residential Care Facility For The Elderly, LIC 9128 (6/99) - Foster Family Agency Program Statement, LIC 9139 (11/16) - Renewal Of Continuing Education Course Approval - Administrator Certification Program, LIC 9140 (11/16) - Request For Course Approval - Administrator Certification Program, LIC 9140A - Request to Add or Replace Instructor, LIC 9148 (9/00) - Earthquake Preparedness Checklist (EPC), LIC 9149 (8/14) - Family Child Care Home Property Owner/Landlord Consent Form, LIC 9150 (8/14) - Parent Notification - Additional Children in Care, LIC 9151 (8/14) - Property Owner/Landlord Notification Family Child Care Home, LIC 9158 (11/04) - Telecommunications Device Notification, 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, LIC 9166 (2/01) - Nebulizer Care Consent/Verification (Child Care Facilities), LIC 9172 (8/01) - Functional Capability Assessment, LIC 9182 (11/15) - Criminal Background Clearance Transfer Request, LIC 9185 (8/08) - Foster Family Agency Certified Home, LIC 9187 (7/00) - Child Care Client Death Report, LIC 9188 (11/15) - Criminal Record Exemption Transfer Request, LIC 9198 (7/01) - Modified Comprehensive Visit Licensee Self-Assessment Staff Qualifications/Records Module Child Care Centers, LIC 9199 (7/01) - Modified Comprehensive Visit Licensee Self-Assessment Children's Records Module Child Care Centers, LIC 9200 (9/11) - Pre-Licensing Facility Evaluation Checklist, LIC 9201 (10/01) - Annual Regulation Compliance Checklist, LIC 9210 (5/06) - Quarterly County Exemption Report, LIC 9211 (1/08) - Request For Inactive Child Care License Status, LIC 9212 (10/05) - Consumer Awareness Information - Family Child Care, LIC 9213 (1/04) - Notice Of Site Visit By A Child Care Licensing Office Representative, LIC 9214 (6/16) - Application For Administrator Initial Certification - Administrator Certification Program, LIC 9216 (3/17) - Complaint And Type A Violation Log, LIC 9217 (3/05) - Pre-Licensing Readiness Guide - Family Child Care Home, LIC 9219 (3/16) - Crisis Nursery Monthly Report, LIC 9219A (3/16) - Crisis Day Care Sign-In, LIC 9221 (8/08) - Parent Consent For Administration Of Medications And Medication Chart, LIC 9222 (9/05) - Blood Glucose Testing Consent/Verification Child Care Facilities, LIC 9223 (4/17) - Child Care Advocate Program, LIC 9224 (8/08) - Acknowledgement Of Receipt Of Licensing Reports, LIC 9225 (4/10) - Pre-Placement Questionnaire, LIC 9226 (5/18) - Request For Training Approval: Mandated Child Abuse Reporter Training, LIC 9227 (8/20) - Individual Infant Sleeping Plan, LIC 9229 (3/20) - Licensing Program Manager (LPM) Checklist For Complaint Review, LIC 9230 (3/20) - Licensing Program Analyst (LPA) Checklist For Complaint Review, LIC 9233 (7/20) – Facility Inspection Checklist Foster Family Agencies, LIC 9234 (7/20) – Entrance Checklist Foster Family Agency, LIC 9235 (7/20) – Facility Inspection Checklist Short – Term Residential Therapeutic Program, LIC 9236 (7/20) – Entrance Checklist Short – Term Residential Therapeutic Program, LIC 9237 (7/20) – Facility Inspection Checklist Transitional Housing Placement Program, LIC 9238 (7/20) – Entrance Checklist Transitional Housing Placement Program, LIC 9239 (7/20) – Entrance Checklist Group Home, LIC 9240 (7/20) – Entrance Checklist Small Family Home, LIC 9241 (2/20) -  Entrance Checklist Adult Care Facilities, LIC 9242 (9/19) -  Entrance Checklist Residential Care Facilities For The Elderly. 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