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The Lic 500 form plays a critical role in the oversight of personnel within California's health and human services facilities. This form is designed to maintain an up-to-date roster of all individuals involved in the operation of a facility, including staff, volunteers, and licensees. It ensures compliance with state regulations by requiring details about personnel who are subject to criminal background checks, as outlined in various sections of the Health and Safety Code. The form also captures essential information about the days and hours each staff member is on duty, which is crucial for ensuring adequate supervision in residential settings. Additionally, it mandates that any changes in personnel be reported to the licensing agency, reinforcing the importance of transparency and accountability. The completed Lic 500 form must be submitted to the licensing agency while a copy is retained on file at the facility, ensuring that all records are readily accessible for review. This proactive approach helps safeguard the well-being of residents and maintains the integrity of care provided in these facilities.

Document Specifics

Fact Name Details
Purpose of the Form The LIC 500 form is used to maintain an up-to-date roster of all personnel and adults residing in a facility, including staff, volunteers, and licensees.
Governing Laws This form is governed by Sections 1522, 1568.09, 1569.17, and 1596.871 of the California Health and Safety Code.
Criminal Background Checks Staff members are subject to criminal background checks as mandated by California law before they can be employed or reside in the facility.
Documentation Requirements The original form must be submitted to the licensing agency, while a copy should be retained in the facility's records.
Staff Categories The form distinguishes between staff members subject to background checks and those believed to be exempt from such checks.
Reporting Changes Any changes in personnel must be reported to the licensing agency as required by regulations.
Facility Information Information such as the facility name, type, and number must be provided at the top of the form for proper identification.

Similar forms

  • LIC 501 - Personnel Report for Child Care Facilities: Similar to the LIC 500, the LIC 501 also maintains a roster of personnel, including their job titles and hours of duty. It specifically focuses on child care facilities, ensuring compliance with state regulations regarding staff qualifications and background checks.

  • LIC 9099 - Application for a License: The LIC 9099 serves as an application form for various types of facilities. Like the LIC 500, it collects essential information about the facility and its operators, ensuring that all necessary details are reported to the licensing agency.

  • LIC 308 - Designation of Facility Responsibility: This document is used to designate individuals responsible for the facility's operations. Similar to the LIC 500, it requires details about the designated persons and their roles, ensuring clarity in management responsibilities.

  • LIC 400 - Application for a Child Care Center License: The LIC 400 is specifically for child care centers and includes information about staff and facility operations. It shares the purpose of documenting personnel and ensuring compliance with health and safety regulations, much like the LIC 500.

  • LIC 610 - Emergency Disaster Plan: The LIC 610 outlines emergency procedures for facilities. While it differs in focus, it still requires detailed information about staff roles and responsibilities during emergencies, reflecting the importance of personnel management similar to the LIC 500.

  • Ohio Medical Power of Attorney Form: To ensure your healthcare decisions are respected, consider completing the important Medical Power of Attorney provisions that allow for trusted guidance in critical times.

  • LIC 9227 - Facility Evaluation Report: This report assesses the compliance of a facility with state regulations. Like the LIC 500, it includes information about staff and operations, helping to ensure that facilities meet required standards for safety and care.

Free Lic 500 File

Lic 500 Example

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.

 

DATE

 

 

SPECIFY

 

 

SPECIFY

 

 

SPECIFY

 

NAME

JOB TITLE

DAYS AND HOURS ON DUTY

DAYS AND HOURS ON DUTY

DAYS AND HOURS ON DUTY

EMPL'D

 

 

DAYS

FROM

TO

DAYS

FROM

TO

DAYS

FROM

TO

 

 

 

Licensee/Administrator

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIC 500 (11/03) (PUBLIC)

Page 1 of 2

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 __________________

NAME

DATE

EMPL'D

JOB TITLE

 

SPECIFY

 

 

SPECIFY

 

 

SPECIFY

 

DAYS AND HOURS ON DUTY

DAYS AND HOURS ON DUTY

DAYS AND HOURS ON DUTY

DAYS

FROM

TO

DAYS

FROM

TO

DAYS

FROM

TO

 

 

 

 

 

 

 

 

 

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Understanding Lic 500

What is the purpose of the Lic 500 form?

The Lic 500 form serves as a personnel report for facilities regulated by the California Department of Social Services. It helps maintain an updated roster of all personnel, including volunteers and other adults residing in the facility. By keeping track of this information, the form ensures compliance with state regulations, particularly regarding criminal background checks for certain staff members. This is essential for safeguarding the well-being of those in care.

Who needs to complete the Lic 500 form?

The Lic 500 form must be completed by the licensee or administrator of the facility. This individual is responsible for accurately reporting all staff members who are subject to criminal background checks, as well as those believed to be exempt from such requirements. Additionally, it is important for any changes in personnel to be reported to the licensing agency, ensuring that the roster remains current and compliant with state regulations.

What information is required on the Lic 500 form?

The form requires several key pieces of information, including the name of the facility, facility type, and facility number. For each staff member, details such as their name, job title, days and hours on duty, and employment dates must be provided. If applicable, the form also requests the license or certificate number for specialized staff, like social workers. This thorough documentation is crucial for effective monitoring and compliance.

What are the criminal background check requirements for staff?

Staff members who are subject to criminal background checks must undergo a clearance process as mandated by California Health and Safety Code sections. This includes obtaining either a California background clearance or a criminal record exemption prior to their employment or presence in the facility. The Lic 500 form plays a vital role in documenting compliance with these requirements, ensuring that all necessary checks are completed before staff begin their duties.

What should be done if there are changes in personnel?

Any changes in personnel must be reported to the licensing agency as required by regulations. It is essential to update the Lic 500 form to reflect these changes promptly. This may include adding new staff members, removing those who have left, or updating job titles and hours. Keeping this information current helps maintain compliance and ensures the safety of all individuals in the facility.

How should the Lic 500 form be submitted?

The original Lic 500 form should be sent to the licensing agency. It is also important to retain a copy of the completed form in the facility's file for record-keeping purposes. This dual submission helps ensure that both the agency and the facility have access to the necessary personnel information, supporting ongoing compliance with state regulations.

Dos and Don'ts

When filling out the Lic 500 form, it is important to follow specific guidelines to ensure accuracy and compliance. Below is a list of things you should and shouldn't do:

  • Do provide accurate information about all facility personnel, including their job titles and hours on duty.
  • Do include the license or certificate number for specialized staff, such as social workers.
  • Do report any changes in personnel to the licensing agency as required by regulations.
  • Do retain a copy of the completed form in the facility file for future reference.
  • Do ensure that all staff members subject to criminal background checks have the necessary clearances before employment.
  • Don't leave any sections of the form blank; incomplete information may lead to delays or issues.
  • Don't submit the form without verifying that all information is current and correct.
  • Don't forget to sign and date the form where required, as this confirms the accuracy of the information provided.
  • Don't assume that all staff are exempt from criminal background checks; verify each individual's status according to the law.

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