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