retain copy of report in client’s file. aFamily Child Care Home license, and to gain access to andprint forms. A Small Family Child Care Home provides care PARENT’S SIGNATURE . Learn more about how family child care homes and child care centers can protect and promote children’s health and safety. A license may be issued for a Small Family Child Care Home or a Large Family Child Care Home. LIC 624B (6/03) SEE INSTRUCTIONS ON REVERSE 16. Community Care Licensing Division Welcome to the Community Care Licensing Division. State Child Care Licensing County Child Care Licensing Child Protective Services Law Enforcement. BRIEFLY DESCRIBE THE INJURY. facility file number . A detailed written report must be filed within 7 days of the event. This health appraisal ... LIC 503 (ENG/SP) (3/99) PERSONAL. Authorized Applicant Type - Enter from list on Page 2, “DOJ … submit written report within 7 days of occurrence. Operators of licensed child care centers have an important role in protecting the health and safety of children. NOTE TO PHYSICIAN: The person specified below is a resident/client of or an applicant for admission to a licensed Community Care Facility. 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 These reports are required of both family child care homes and centers. community care licensing division unusual incident/injury report instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. 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 … ORI: A0448 CA Dept of Social Services PO BOX 944243 Sacramento, CA 94244-2430 LIC 9163 (10/15) PAGE 1 OF 4 3. Save or instantly send your ready documents. REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING Applicant Submission 1. View, download and print Lic 624 - Unusual Incident/injury Report pdf template or form online. 2. 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 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. 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. Comments and Help with california licensing form lic 624. This website includes videos that explain licensing topics relevant to families and licensed child care providers. instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. COMMUNITY CARE LICENSING . Watch these brief, informative videos to learn more about putting Licensing requirements into practice. Download our form. 0 %%EOF 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. This app includes all the detailed information necessary to complete form LIC 624. STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY, NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND. And suspected child abuse cases must also be reported to a child protective agency. outbreak of a communicable disease) are to be reported to the Department of Public Health. Reports of any kind of criminal violation are to be filed to local law enforcement authorities. CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT . cdss vendor: arf #2000079-735-2. brn #cep16081. 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. Keep current - Return a copy to the licensing office. 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. Google Translate. nasw #886756920. rcfe #2000079-740-2. strtp #2000079-733-2. rcfe ictp #2000079-740-1 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. endstream endobj startxref REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING Applicant Submission 1. 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. Licensing Forms. Easily fill out PDF blank, edit, and sign them. submit written report within 7 days of occurrence. The phone reports are made no later than the next working day after the event occurs. All rights reserved. community care licensing division death report licensee must report the death of a client of any cause, regardless of where the death occurred. 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