Content Overview
The Lic 500 form is a crucial document for facilities operating under the California Department of Social Services. It serves as a personnel report, ensuring that all staff members, volunteers, and other adults residing in the facility are properly documented. This form is designed to maintain an up-to-date roster, which includes essential details such as job titles, days and hours of duty, and any applicable license or certificate numbers for specialized staff like social workers. Compliance with regulations is paramount; therefore, facilities must report any changes in personnel to the licensing agency promptly. Additionally, the Lic 500 outlines specific requirements regarding criminal background checks, detailing which staff members must undergo this process and who may be exempt. By signing the form, the licensee or designated representative affirms their belief in the exemptions claimed. The original form must be submitted to the licensing agency, while a copy should be kept in the facility’s records for future reference. Understanding the Lic 500 form is essential for maintaining compliance and ensuring the safety and well-being of all individuals within the facility.
Key takeaways
Here are key takeaways about filling out and using the Lic 500 form:
- The Lic 500 form is essential for maintaining an up-to-date roster of all personnel in a facility.
- It includes information on employees, volunteers, and licensees residing in the facility.
- Specialized staff, such as social workers, should include their license or certificate number on the form.
- The form ensures that there is coverage for twenty-four-hour supervision in residential facilities.
- Any changes in personnel must be reported to the licensing agency as required by regulations.
- Submit the original form to the licensing agency and keep a copy in the facility's file.
- Staff members subject to criminal background checks must have a clearance or exemption before starting work.
- Exempt staff must be verified by the licensee or designated representative's signature on the form.
- Clearly specify the days and hours on duty for each staff member listed.
- Ensure that the form is completed accurately and submitted in a timely manner to avoid compliance issues.
Guide to Writing Lic 500
Completing the Lic 500 form requires attention to detail and accuracy. This form is essential for maintaining a current roster of personnel associated with a facility. After filling out the form, it is important to send the original to the licensing agency and keep a copy for your records.
- Begin by entering the NAME OF FACILITY at the top of the form.
- Next, specify the FACILITY TYPE and FACILITY NUMBER.
- Fill in the PREPARED BY section with your name and the DATE of completion.
- In section A, list the staff members subject to criminal background check requirements. For each individual, provide the following details:
- NAME
- JOB TITLE
- DAYS AND HOURS ON DUTY (specify days employed and the hours worked)
- In section B, identify staff exempt from criminal background check requirements. For each individual, include:
- NAME
- DATE EMPLOYED
- JOB TITLE
- DAYS AND HOURS ON DUTY (specify days employed and the hours worked)
- Have the licensee or designated representative sign the verification statement in section B.
- Finally, ensure that the form is dated and review all entries for accuracy before submission.
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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
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.
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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
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Page 2 of 2
Documents used along the form
The Lic 500 form plays a crucial role in maintaining a comprehensive record of personnel in facilities regulated by the California Department of Social Services. However, it is often accompanied by several other important documents that support compliance and operational integrity. Understanding these documents is essential for effective facility management and adherence to state regulations.
- LIC 501 - Personnel Report: This form is used to document staff members who are employed at the facility. It includes detailed information about each employee, such as their job title, responsibilities, and employment dates, ensuring that all personnel records are accurate and up-to-date.
- LIC 508 - Criminal Record Statement: This document is required to confirm that all staff members have undergone the necessary background checks. It serves as a declaration that the facility complies with state regulations regarding criminal history for personnel working with vulnerable populations.
- LIC 610 - Emergency Disaster Plan: This plan outlines the procedures and protocols the facility will follow in case of emergencies, such as natural disasters or other crises. It ensures that staff and residents are prepared and that safety measures are in place.
- LIC 9148 - Staff Training Records: This form tracks the training and professional development of staff members. It is essential for ensuring that employees meet the required qualifications and are equipped to provide high-quality care.
- LIC 9227 - Facility Evaluation Report: This report assesses the overall operation and compliance of the facility with state regulations. It is crucial for identifying areas for improvement and ensuring that standards are met.
- LIC 9102 - Admission Agreement: This document outlines the terms and conditions of residency for individuals admitted to the facility. It is important for protecting both the rights of residents and the responsibilities of the facility.
- Motor Vehicle Bill of Sale: This form is essential for documenting the sale of a vehicle in Texas, serving as a vital proof of the transaction and ensuring both buyer and seller understand the agreement. For more information, visit smarttemplates.net.
- LIC 700 - Health Screening Report: This report is used to document the health status of residents upon admission. It is vital for ensuring that the facility can provide appropriate care and respond to any medical needs.
- LIC 9050 - Incident Report: This form is used to report any significant incidents or accidents that occur within the facility. Timely reporting is essential for compliance and for addressing any issues that may arise.
In summary, the Lic 500 form and its accompanying documents are integral to the operation of facilities under the jurisdiction of the California Department of Social Services. Keeping these records accurate and up-to-date is not just a regulatory requirement; it is a commitment to the safety and well-being of all individuals involved. Facilities must prioritize these documents to ensure compliance and foster a culture of accountability and care.