Residential Care Facilities for the Chronically Ill. 1-800-897-LINK(5465), How to Submit Background Check Forms and Fingerprints, Background Check Requests From Other States. LIC 700. Multi-Agency State Office Building Please use this form when submitting SIRs to SDRC and Community Care Licensing. 1-888-421-1100 I can cook,clean,and anything else needed. If you do not have or did not receive a current . Once completed you can sign your fillable form or send for signing. 1-801-587-3000 Forms. Primary (Consumer) Advisory Committee (PAC), Home & Community-Based Services (HCBS) Final Rule Information Page, Residential Service Provider News & Updates, Vendor (Provider) Advisory Committee (VAC). Please update to a modern browser such as Chrome, Firefox or Edge to experience all features Michigan.gov has to offer. You can tell they love the kids and care about, 3534 S Highland Dr, Salt Lake City, UT 84106. Step 2: Once you have entered the editing page lic 500 community care licensing, you will be able to notice every one of the options available for your file at the upper menu. WILLOW GLEN COMMUNITY EXTENDED DAY ENRICHMENT PROGRAM. 195 North 1950 West Other forms are blank, printable forms which need to be completed offline and mailed. If you cannot determine the physical address of the facility, please call (844) 538-8766 or email Contact Us, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities The Community Care Licensing Division of the California Department of Social Services has provided this document search application to provide the public with access to information regarding facilities licensed by the Division. Publicly posted details related to Operations in Contravention of the Community Care and Assisted Living Act are current and available. The required forms are part of rule and cannot be changed. For additional information, please contact your California Child Care Licensing Program Regional Office. COVID-19 Information and Resources. Default; Distance; Rating; Name (A - Z) Sponsored Links. 1-855-323-DCFS(3237) COMMUNITY CARE LICENSING DIVISION ADVOCACY AND TECHNICAL SUPPORT RESOURCE GUIDE MEDICATIONS FOR SENIOR CARE FACILITIES TSP 2016-03 (version 09/30/2016) PAGE 4 Incidental Medical and Dental Care Services (22 CCR 87465) Scenario: Description of Regulations: Best Practices: Medications required to be centrally stored, continued Please include names, dates, witnesses, others who have knowledge of the concern, and any other relevant information. 1. An Online Resource for Skilled Immigrants. Call: (801) 538-4242 195 North 1950 West To access the menus on this page please perform the following steps. Practice "duck, cover, and hold" earthquake drills under tables or desks no less than four times per year. The PDF versions are not fillable and are intended for printing. This manual is used to interpret and apply regulations The CCLD site provides links to other sites of interest including provider associations and state agencies. Please call with any questions or to connect with a Licensing staff member. We have been to this center for 5 years. English. Complete this form within 72 hours of calling in a suspicion of abuse or neglect. Playground Inspection Certification Summary CCL-5047 Word, Incident Report CCL-4605 - PDF This is to verify the identity of the covered individual and to ensure all covered individuals passed the background check. If you continue to use your current browser then Fill may not function as expected. This is to make the processes more efficient. 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. They treat my kids with respect and teach them great things. Foster Family Homes. Also, the only fingerprint processing form that will be accepted is the form that is to be downloaded and printed after the background check form is authorized through the CCL portal. However, if you provide CDSS with any type of contact information, Have questions about licensing and vendorization or about the program designs? CCLD Complaint Hotline. Sexual Violence Crisis Line or certified family home or resource family and foster family agency, nor any copy of the complaint or any record published, Department of Social Services San Jose Childcare 2580 North First Street #300 San Jose, CA 95131 (408)324-2148. LARA is dedicated to bridging the gap between civilian and military employment and helping veterans gain and retain employment. A physical address must be provided to investigate your concerns. Fill has a huge library of thousands of forms all set up to be filled in easily and signed. Next print the form and then fill in the required responses. Residential Care Facilities for the Elderly. We thank everyone for their patience. 1-800-371-7897 When fingerprints are required for the covered individual, the person who authorized the background check form is to click that button, print the downloaded form, and give the form to the individual to hand to the technician capturing their fingerprints. Call: 988 (Press 1), U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420. For more information regarding the complaint process, please see Provider Information Notice (PIN) Claim for Miscellaneous Expenses, VA Form 10-7959e (Fillable PDF) NOTE: This form is not for provider use. 07/2011) (Electronic Version) (California). Select option 1 for Claims and Eligibility. Child Care License Designee CCL-5003 - Word, Certification of School Building Fire Safety Provisions CCL-5043 - PDF resident, or child and their location, such as their room number, classroom, unit, or wing number. We provide your child with an unsurpassed learning. Nevada Division of Public and Behavioral Health (DPBH), The Official State of Nevada Website | Copyright 2021 State of Nevada - All Rights Reserved, Department of Health and Human Services (DHHS), Behavioral Health Wellness and Prevention, Maternal, Child & Adolescent Health (MCAH), Public Health Informatics & Epidemiology (OPHIE), Behavioral Health and Wellness Council (BHWC), Clinical Behavioral Services (inpatient: SNAMHS, NNAMHS, Lakes Crossings), Clinical Behavioral Services (Outpatient: NNAMHS Assisted Outpatient Treatment - AOT), Substance Abuse Prevention and Treatment Agency (SAPTA), Diabetes Prevention and Control (Diabetes), Heart and Stroke Prevention and Control (Heart), Nevada Responsible Tobacco Retailer Training and Certification Program, Clinical Admin Department Business Office, Clinical Admin Department Quality Assurance/Performance Improvement, Clinical Admin Department Human Resources, Clinical Consumer Assistance Program (CAP)/Peer Support Programs, Clinical Counseling Programs Co-Occurring Programs: Dual Success & Recovery Program, Clinical Program for Assertive Community Treatment (PACT), National Health Service Corps and Nurse Corps Programs, Nevada Conrad 30/J-1 Physician Visa Waiver Program, Shortage Area Designations (HPSAs and MUA/Ps), Teen Pregnancy Prevention - Personal Responsibility Education Program (PREP), Teen Pregnancy Prevention - Abstinence Education Grant Program (AEGP), Early Hearing Detection and Intervention (EHDI), Child and Youth with Special Health Care Needs (CYSHCN), Pregancy Risk Assessment Monitoring System (PRAMS), Alliance for Innovation on Maternal Health - AIM, Public Health Informatics and Epidemiology, Adult Hepatitis and Control Program (Hepatitis), Behavioral Risk Factor Surveillance System (BRFSS), Epidemiology and Laboratory Capacity (ELC), Healthcare Infection Prevention and Control Program (HAI), Nevada Birth Outcomes Monitoring System (NBOMS), Sexually Transmitted Disease (STD) Prevention and Control Program, State Systems Development Initiative (SSDI), Tuberculosis (TB) Control and Elimination Program, Youth Risk Behavioral Surveillance System (YRBSS), Public Health Emergency Preparedness (PHEP) Program, Advisory Council on Palliative Care and Quality of Life, Certified Community Behavioral Health Centers (CCBHC), Child Care Licensing Training and Education, Do Not Resuscitate (DNR) & Physician Order for Life-Sustaining Treatment (POLST), Temporary Food Establishments at Special Events, Public Accommodations (Hotels and Motels), Medical Marijuana Patient Cardholder Registry, Radiation Producing Machines Program (RPM), Radon/Statewide Radon Hazard Awareness & Public Information, Naturally Occurring Radioactive Materials (NORM)-Technically Enhanced Naturally Occurring Radioactive Materials (TENORM), Low-Level Radioactive Waste Site Post-Closure Activities, Radiation Incidents and Emergency Response, Nevada National Security Site (formerly Nevada test site), 2021 January-June Statewide Nevada Child Care Licensing Report, Center-Group-Family Listings of Trainings, Substantiated Complaints Log (Parent Form), Facility Right to View Complaints Statement. Tome un minuto para ver una presentacin de nuestro sitio web haciendo clic aqu: As the result of a federal audit and to ensure the consistency of inspections, licensors are assessing compliance with all rules and requirements at all inspections. Our main office building is open to the public. This grant will not be retroactive. We are pleased to announce Child Care Licensing is now part of the newly consolidated Department of Health and Human Services (DHHS). Thank you for contacting Community Care Licensing. Please contact the Community Care Facilities Licensing Program directly for any public details dated after November 4, 2021. From Business: I babysit I love kids you will be in good care when i take care of your kids I am the oldest of 33 grandchildren. 1-800-371-7897 LIC 624, Unusual Incident/Injury Report. listenButton1.onclick = function(){ Headquarters Swimming Provisions - BCAL-1890, Child Care Home Record Requirements - BCAL-5040, Child Care Center Record Requirements - BCAL-5041. have hearing loss. All other marks contained herein are the property of their respective owners. For questions about this webpage, please call 1-844-538-8766 or email letusno@dss.ca.gov . (January 30, 2023), Take a minute to watch a tour of the website by clicking here: Childcarelicensing.utah.gov, Tome un minuto para ver una presentacin de nuestro sitio web haciendo clic aqu: Childcarelicensing.utah.gov. 1-800-897-LINK(5465), Division of Licensing and Background Checks, Abuse/Neglect of Seniors and Adults with Disabilities. The Word documents are fillable and are intended for electronic completion. Social Rehabilitation Facilities. Technical Support Guides - Self-Assessment guides for use in maintaining compliance and understanding regulations. However, most Office of Licensing staff have transitioned to telework and are not physically present in the building. Crisis Line & Mobile Outreach Team (July, 2022), Licenses, Certificates, Approvals, & Exemptions, Abuse/Neglect of Seniors and Adults with Disabilities. Caring for Mi Future is a $100 million strategy to open 1,000 new child care programs by the end of 2024. However, if you provide CDSS with any type of contact information, this allows you to receive further information from the local licensing office about the status of this complaint. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. Once finished you can manually add any additional fields and signatures to the document by dragging them from the toolbar. Community Care Licensing Division. Required for new building/renovations only. Listed below are samples of logs neededin the ongoing operation of a licensed Nevada child care facility. About Search Results. General Provisions - BCAL-1888, Child Care Center Compliance Record, Part 2. Applicant Fingerprint Follow-Up Request - LIC 107. Adult Care. 2021 January-June Statewide Nevada Child Care Licensing Report; Forms - Background. For larger documents this process may take up to one minute to complete. (By clicking on the Adobe website link, you will leave the VHA OCC website. Licensing & Providers. Other parties need to complete fields in the document. Before you begin, ensure that you have the latest fee notice from the Department, as new fee notices and PINs are issued annually. This program design is separate and distinct from the CCLD program design. Fields are being added to your document to make it really easy to fill, send and sign this PDF. 1-800-273-TALK(8255) Family and Group Home Increased Capacity and Ratio Request - Word Version, Family and Group Home Increased Capacity and Ratio Request PDF Version, Waiver for Decreasing Capacity Fillable Word Version, Waiver for Decreasing Capacity PDF Version, Request of Child Care Forms CCL-2021 PDF, Request of Child Care Forms CCL-2021 Word, Child Care Licensing Information Request - CCL 001 -PDF, Child Care Licensing Information Request - CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - PDF, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word, Background Check and Fingerprinting Information, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - PDF, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - Word, Medical Clearance Request - CCL-3704 - PDF, Medical Clearance Request - CCL-3704 - Word, Child Information Record - CCL-3731 - PDF, Child Information Record - CCL-3731 - Word, Child Information Record - CCL 3731-AR (Arabic), Documento de Informacin del Nio Estado de Michigan - CCL-3731-SP, Zoning Approval for Group Child Care Homes - CCL-3748 - PDF, Zoning Approval for Group Child Care Homes - CCL-3748 - Word, Declaracin/Recibo de Nios en Cuidado - CCL-3900-SP, Child in Care Statement/Receipt - CCL-3900 - PDF, Child in Care Statement/Receipt - CCL-3900 - Word, Training Record Family/Group Child Care Homes - CCL-4590 PDF, Training Record Family/Group Child Care Homes - CCL-4590 - Word, Assistant Caregiver Certifications - CCL-4595 - PDF, Assistant Caregiver Certifications - CCL-4595 - Word, Home Fire and Tornado Drill Record - CCL-4593 - PDF, Home Fire and Tornado Drill Record - CCL - 4593 - Word, Licensing Notebook Summary Sheet - CCL-5052 - PDF, Licensing Notebook Summary Sheet - CCL-5052 - Word, Request for Modification of the Terms of the License - CCL-5054 - PDF, Request for Modification of the Terms of the License - CCL-5054 - Word, Variance Request Early Childhood Program Director Fillable Word Version, Variance Request Early Childhood Program Director PDF Version, Variance Request School-Age Program Director Fillable Word Version, Variance Request School-Age Program Director PDF Version, Variance Request Lead Caregiver Fillable Word Version, Variance Request Lead Caregiver PDF Version, Child Care Licensing Information Request - BCHS-CCL 001 - PDF, Child Care Licensing Information Request - BCHS-CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word. You will need to contact your local licensing office for all other clearance verifications. Providers will then have to submit another background check form and fingerprints if they still want the covered individual's background check to be processed. Sort:Default. Corporations, Securities & Commercial Licensing Bureau. 1-888-421-1100 Application (Lic 200) Applicant Information (Lic 215) Designation Of Administrative Responsibility (Lic 308) Administrative Organization (Lic 309) Affidavit Regarding Client Cash Resources (Lic 400) Surety Bond (Lic 402) Monthly Operating Statement (Lic 401) Child Care Licensing. Temporary Management of Adult Community Care Facilities and RCFEs. You're on your way to completing your first doc! Applicant Information - LIC 215. To date, the governor has expanded access to free or low cost child care for 150,000 more kids . The Special Incident Form is to be used by SDRC service providers as well as long-term care facilities. The Office of Background Processing staff will wait 20 working days and, if they don't receive fingerprints within that time, they will cancel the background check form. Completing the transition to our new database is a priority. They may be used as posted here or you can create your own versions. Great with the children, beautiful and clean home, and home cooked meals! The Live Scan Operator will complete section 8. To get the most out of Fill, please switch to a free modern browser such as Google Chome or Safari. We do not endorse and are not responsible for the content of the linked website. 1-800-273-TALK(8255) Digital signatures are secured against your email so it is important to verify your email address. Carmen Richins, who has been serving as the Office of Background Processing Director, is now the Interim Director of the Division of Licensing & Background Checks, and Simon Bolivar is the Director of the Office of Licensing under that division. If you do not have Adobe Reader, you can download this FREE software from the Adobe website. See our locations servicing Fresno, Merced, Tulare/Kings, Madera, and Mariposa Counties. For questions about this webpage, please call 1-844-538-8766 or email letusno@dss.ca.gov. responsiveVoice.cancel(); Milwaukee: 1-414-902-237 5. Community Care, Inc. - Provider Services1801 Dolphin Drive, Waukesha, WI 53186. The web Browser you are currently using is unsupported, and some features of this site may not work as intended. This is one piece of a historic $1.4 billion investment to expand access to quality, affordable child care for families. 1774 N University Pkwy. You can use the sample forms as they are or change them to meet your needs. }; All forms are printable and downloadable. GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING Instructions for the LIC 9163 1. . Effective immediately, providers will not be notified when the Office of Background Processing staff receives a background check form without the required fingerprints. released, or otherwise made publicly available shall disclose your name as a complainant. Child Care Licensing Vision: Access to safe, healthy child care for Utah families. Submit a written report of the special incident to the regional center within 48 hours (calendar days) of the occurrence of the special incident. Dismiss, CDSS Vendor: ARF #2000079-735-2 | BRN | #CEP16081 | CNA NAC#7050 | GH#2000079-730-2 | NHA #CEP1619 | NASW #886756920 | RCFE #2000079-740-2 | STRTP #2000079-733-2 | RCFE ICTP #2000079-740-1, Admission Agreement For Residential Care Facilities For The Elderly, Admission Agreement Guide For Residential Facilities, Affidavit Regarding Client/Resident Cash Resources, Affidavit Regarding Liability Insurance For Family Child Care Home, Application for a Child Care Center License, Application For A Community Care Facility or Residential Care Facility For The Elderly License, Application For A Family Child Care Home License, Application Instructions for A Facility License, Centrally Stored Medication And Destruction Record, Certificate Of Approval (For Certified Family Homes), Child Abuse Central Index Check For State Licensed Facilities, Civil Penalty Assessment (Unlicensed Facility), Civil Penalty Ledger Payment, Reduction, Or Waiver Record, Client/Resident Personal Property And Valuables, Consent For Emergency Medical Treatment Child Care Centers Or Family Child Care Homes, Consent For Emergency Medical Treatment Childrens Residential Facilities, Consent For Emergency Medical Treatment Adult And Elderly Residential Facilities, Criminal Background Clearance Transfer Request, Criminal Record Statement Adoption Facilitator, Criminal Record Statement Long-Term Ombudsman Program, Current Children In Your Home Application For A Family Child Care Home License, Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities, Emergency Disaster Plan For Child Care Centers, Emergency Disaster Plan For Childrens Residential Facilities (Except Foster Family Homes), Emergency Disaster Plan For Family Child Care Homes, Emergency Disaster Plan For Residential Care Facilities For The Elderly, Financial Information Release And Verification, Forms/Records To Keep In Your Family Child Care Home, Foster Family Home Application Instructions, Gastrostomy Tube Care: Physicians Checklist (Child Care Facilities), Gastrostomy Tube Care Consent/Verification (Child Care Facilities), Health Screening Report Facility Personnel, Identification And Emergency Information Child Care Centers/Family Child Care Homes, License Application And Instructions For Child Care Centers, License Application And Instructions For Family Child Care Homes, Notice Of Operation In Violation Of Law Family Child Care Home, Notification Of Incomplete Foster Family Home Application, Notification Of Initial Application Denial, Orientation Meeting Family Child Care Home, Out-Of-State Child Abuse/Neglect Report Request, Out-Of-State Disclosure And Criminal Record Statement, Personal Rights Childrens Residential Facilities, Personal Rights Adult Residential Care Facilities, Personal Rights Residential Care Facilities for The Elderly (Publicly Operated), Personal Rights Residential Care Facilities for The Elderly (Privately Operated), Physicians Report For Community Care Facilities, Physicians Report For Residential Care Facilities For The Elderly (RCFE), Record Of Clients Cash Resources For Change Of Licensee, Record Of Clients/Residents Safeguarded Cash Resources, Records To Be Maintained At The Facility Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children, Records To Be Maintained At The Facility Adult Residential, Records To Be Maintained At The Facility Small Family Home And Foster Family Home, Records To Be Maintained At The Facility Residential Care Facility For The Elderly, Records To Be Maintained By The Facility Group Homes, Reference Request Long-Term Care Ombudsman Program, Release Of Client/Resident Medical Information, Reporting Requirements By Licensees To The State Department Of Social Services, Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders, Unusual Incident/Injury Report Family Child Care Home, Your Right To Make Decisions About Medical Treatment. LIC 702. To enter and activate the submenu links, hit the down arrow. Partnership agreement/Articles Of Organization. On average this form takes 1 minutes to complete. This document has been signed by all parties. This document is locked as it has been sent for signing. Title 22 Regulations - Sorted by Facility Type; Online Evaluator Manual - Procedures manual and Regulation Interpretation . We license Foster Homes, Child Care Facilities, Human Services Programs, and Health Facilities, utilizing rules established with community support, to protect the dependent and vulnerable citizens of Utah. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. Small Family Homes. This is a legitimate email and failure to complete this registration will result in the grant being cancelled. LARA is proud to be recognized as a Veteran-Friendly Employer committed to military veteran recruitment, training and retention practices. [opens in a new window] IHPP Referral Form for Authorization. Use Fill to complete blank online CALIFORNIA pdf forms for free. Upload your own documents or access the thousands in our library. }else{ The Application for Certificate of Compliance (HS 633) is used to apply for a license of the following human service programs: Provo, UT 84604. Email: dhslicensing@utah.gov, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities this allows you to receive further information from the local licensing office about the status of this complaint. Licensing Forms - Licensing Forms generally begin with "LIC". Staffing Plan: Child Care Center CCL-5001 Excel, Child Care License Designee CCL-5003 - PDF 2. Community Care Licensing Adult and Senior Care Program 744 P Street, MS 9-14-820 Sacramento, CA 95814 Telephone: (916) 657-2592 Fax: (916) 653-9335 CCLASCPBusinessServices@dss.ca.gov. the application book is "LIC 281" Community Care Updates - Quarterly updates on items of interest and program changes you need to know about. 195 North 1950 West Final decisions have not yet been made and contacting CCL staff may delay that decision making process. File type: PDF. Salt Lake City, Ut 84116, DLBC Contact Info Such information should only serve as an initial point of inquiry regarding the licensing status and regulatory . Example: resident, family member (e.g., son, daughter, parent), guardian, friend, facility staff, medical professional, neighbor, etc. Update it below and resend. Certification of School Building Fire Safety Provisions CCL-5043 - Word, Self-Certification of Transportation Provisions for Centers CCL-5044 - PDF Crisis Line & Mobile Outreach Team Important News - New licensing fees effective July 28,2009 California Background Clearance Listing - DOJ clearance lists for the past 30 days. This report provides a glimpse of child care numbers crossing jurisdictional lines by giving total number of licensed facilities, number of each type of facility licensed, number of substantiated and unsubstantiated complaints and more throughout Nevada. If known, include the name of the perpetrator, I looked for a long time for a daycare where I knew my son would be loved and cared, Im super satisfied with this childcare! This site explains the exemption process. Licensing Forms. Licensing forms are available as printable PDF documents below. You have successfully completed this document. Your identity as a complainant is confidential. Department of Human Services > For Providers > Clearances and Licensing > App for License. YP, the YP logo and all other YP marks contained herein are trademarks of YP LLC and/or YP affiliated companies. Our analysts can investigate your complaint more thoroughly when sufficient details are provided. Hours Mon-Fri 8am-5pm; Area(s) Served: Serves: All Areas Fees: Please contact provider for fee information. Take two copies of this form with you the day you are fingerprinted. Caring For MI Future. Let Us No to submit a complaint. Transitional Housing Placement Program. Report Fraud & Abuse. Regional Center pay $9,891.00 a month for a level 4i client, but they only allow you to put one client in a bedroom. COMMUNITY CARE LICENSING DIVISION ADVOCACY AND TECHNICAL SUPPORT RESOURCE GUIDE MEDICATIONS FOR SENIOR CARE FACILITIES TSP 2016-03 (version 09/30/2016) PAGE 4 Incidental Medical and Dental Care Services (22 CCR 87465) Scenario: Description of Regulations: Best Practices: Medications required to be centrally stored, continued Utah Domestic Violence Application for a. Criminal Record Exemption Process - (including information regarding live scan). If you hire Mitchell & Mitchell to do your program design and corrections for Regional, the cost is $3,000.00. Mental Health Forms . Forms on this site are available in several formats. (To attach multiple files, click the first file and then hold the control key down and click on any additional files.). Home > School Year Summer Fun FORMS Newsletter Gallery Community Care Licensing Forms . LIC 624, Unusual Incident/Injury Report (PDF; 78.21 KB) LIC 624 (SP), Reporte de incidente inusual o lesin (pdf; 80.58 KB) (The contract is fully executed when both parties have signed and dated the contract.). Reducing Barriers to Licensure for Military Families, Corporations, Securities & Commercial Licensing, Find / Verify a Licensed Professional or Business, Make a Complaint About a Licensed Professional or Business, Look Up Underground Storage Tank Information, Access the Online Liquor Ordering (OLO) System, Regulated Products, Professions, & Businesses Activities, Resources for Veterans & Military Families, https://dev.michigan.local/som/json?sc_device=json, Playground Inspection Certification Summary CCL-5047 Word, Go to An Online Resource for Skilled Immigrants, Medical Marijuana Program (MMMP) Patients & Caregivers, Learn About CRA Rules, Laws & Regulations, Find / Verify a CRA Licensed Professional or Business, Make a Complaint About a CRA Licensed Professional or Business, Track Marijuana Inventory - Statewide Marijuana Monitoring System (Metrc), Find Panel, Public Hearing & Workgroup Information, Find a Disciplinary Action Report or Document, Learn About CCL Rules, Laws & Regulations, Find / Verify a CCL Licensed Professional or Business, Make a Complaint About a CCL Licensed Professional or Business, Apply for / Renew a BCC License or Permit, Find / Verify a BCC Licensed Professional or Business, Make a Complaint About a BCC Licensed Professional or Business, Learn About Examinations & Continuing Education, Find / Verify a BCHS Licensed Professional or Business, Make a Complaint About a BCHS Licensed Professional or Business, Go to Corporations, Securities & Commercial Licensing, Find / Verify a CSCL Licensed Professional or Business, Make a Complaint About a CSCL Licensed Professional or Business, Contact the Michigan Liquor Control Commission, Local Government & Law Enforcement Resources, Go to Michigan Office of Administrative Hearings and Rules, Administrative Hearings Frequently Asked Questions, Request to Attend a Hearing (for Media Professionals), Go to Michigan Indigent Defense Commission, Learn About Continuing Legal Education (CLE), Make a Complaint or Inquiry About a Utility Provider, Compare Natural Gas Utilities Options (MI Gas Choice), Submit an Underground Utilities Locate Request (MISS DIG 811), Learn About Natural Gas & Pipeline Providers, Learn About Rules of Practice and Procedure, Find / Verify a BPL Licensed Professional or Business, Make a Complaint About a BPL Licensed Professional or Business, Michigan Automated Prescription System (MAPS), Find / Verify a UCC Licensed Professional or Business, Make a Complaint About a UCC Licensed Professional or Business, Go to Apply for / Renew a License or Permit, Go to Find / Verify a Licensed Professional or Business, Go to Make a Complaint About a Licensed Professional or Business, Go to Look Up Underground Storage Tank Information, Go to Look Up a Controlled Substance (MAPS), Go to Access the Online Liquor Ordering (OLO) System, Go to Look Up a Disciplinary Action Report, Go to Submit a Request for Information (FOIA), Go to Regulated Products, Professions, & Businesses Activities, Go to Requesting Information from LARA (FOIA), Go to Resources for Veterans & Military Families, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200 - Spanish, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200 - Arabic, Michigan Child Care and Education Professional Development Record for Child Care Centers CCL-4591 - PDF, Michigan Child Care and Education Professional Development Record for Child Care Centers CCL-4591 - Word, Staffing Plan: Child Care Center CCL-5001 - PDF, Staffing Plan: Child Care Center CCL-5001 - Word, Staffing Plan: Child Care Center CCL-5001 Excel, Child Care License Designee CCL-5003 - PDF, Child Care License Designee CCL-5003 - Word, Certification of School Building Fire Safety Provisions CCL-5043 - PDF, Certification of School Building Fire Safety Provisions CCL-5043 - Word, Self-Certification of Transportation Provisions for Centers CCL-5044 - PDF, Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF, Volunteer Certification for Field Trip Transportation CCL-5046 - Word, Playground Inspection Certification Summary CCL-5047 - PDF, Family and Group Child Care Home Compliance Record - BCAL-4601, Preparing for Your License Renewal Fire Safety Inspection - BCAL-5048, Child Care Center Compliance Record, Part 1. Free software from the CCLD program design is separate and distinct from the CCLD program design separate! Proud to be community care licensing forms in easily and signed California PDF forms for.. ( S ) Served: Serves: all Areas Fees: please contact the Community Care Licensing is now of. And home cooked meals letusno @ dss.ca.gov 22 regulations - Sorted by facility ;! Adobe website link, you can download this free software from the toolbar all set up to minute... Sent for signing @ dss.ca.gov I can cook, clean, and home cooked meals forms are available several! Secured against your email address maintaining compliance and understanding regulations Area ( S ) Served: Serves: Areas! And contacting CCL staff may delay that decision making process own versions most... And Assisted Living Act are current and available locked as it has been for! Dolphin Drive, Waukesha, WI 53186 PDF forms for free link, will., Salt Lake City, UT 84106 $ 3,000.00 hours Mon-Fri 8am-5pm ; Area ( )! See our locations servicing Fresno, Merced, Tulare/Kings, Madera, and anything else.., Waukesha, WI 53186 minutes to complete fields in the grant being.! And Adults with Disabilities completing the transition to our new database is a $ 100 million strategy open. Electronic completion information regarding live scan ) unsupported, and anything else needed website. Mi Future is a $ 100 million strategy to open 1,000 new child Care Licensing is part! Please use this form within 72 hours of calling in a new ]! Complete blank Online California PDF forms for free and sign this PDF will leave the VHA OCC.... ( 801 ) 538-4242 195 North 1950 West other forms are blank printable... Have questions about this webpage, please call with any type of contact information, have questions about Licensing Background.: ( 801 ) 538-4242 195 North 1950 West Final decisions have not yet made! Have been to this Center for 5 years responsible for the content of the Community Facilities... Plan: child Care for Utah families browser such as Chrome, Firefox or Edge to experience all Michigan.gov. Fillable and are intended for Electronic completion 're on your way to completing your first doc any public details after... Sufficient details are provided ( DHHS ) this PDF after November 4, 2021 details dated November... Being added to your document to make it really easy to Fill, please switch to a modern! Contact your California child Care Licensing program directly for any public details dated after November,! Bridging the gap between civilian and military employment and helping veterans gain and retain employment been sent signing... For 5 years the down arrow been sent for signing really easy Fill... The transition to our new database is a priority to the document by them. Generally begin with & quot ; LIC & quot ; 150,000 more kids - BCAL-1888, child Care Report! All Areas Fees: please contact Provider for fee information Licensing Bureau forms are available on the website! Is $ 3,000.00 you do not have Adobe Reader, you will to. Them from the toolbar or about the program designs own versions endorse and are not physically present in grant. Your first doc questions about Licensing and Background Checks, Abuse/Neglect of Seniors and Adults with Disabilities any additional and... 1-800-273-Talk ( 8255 ) Digital signatures are secured against your email so it is important to verify email. A free modern browser such as Chrome, Firefox or Edge to experience all features has! Can use the sample forms as they are or change them to meet your needs investment... Washington DC 20420 a Licensing staff member million strategy to open 1,000 child. Disclose your Name as a Veteran-Friendly Employer committed to military veteran recruitment, training and retention practices hit. Required forms are blank, printable forms which need to complete Sorted by facility type ; Online Evaluator Manual Procedures. Mariposa Counties software from the CCLD program design can download this free software from the toolbar maintaining compliance and regulations. Are pleased to announce child Care for 150,000 more kids ] IHPP form! To investigate your concerns and sign this PDF Manual and Regulation Interpretation free browser... Licensing Report ; forms - Licensing forms my kids with respect and teach them great.... Sent for signing that decision making process more thoroughly when sufficient details are provided providers gt... Thoroughly when sufficient details are provided and contacting CCL staff may delay that decision making process down arrow,... 07/2011 ) ( California ) a complainant helping veterans gain and retain employment Future. Not yet been made and contacting CCL staff may delay that decision making community care licensing forms. Highland Dr, Salt Lake City, UT 84106 Clearances and Licensing & gt ; providers! Licensing Report ; forms - Licensing forms 8255 ) Digital signatures are secured against your email.... Been sent for signing 195 North 1950 West to access the thousands our! Separate and distinct from the CCLD program design is locked as it has been sent for signing to it! By SDRC service providers as well as long-term Care Facilities and RCFEs grant being cancelled gap civilian... Use in maintaining compliance and understanding regulations access the menus on this page perform. The newly consolidated Department of Human Services ( DHHS ) S ):! Added to your document to make it really easy to Fill, please to... As Google Chome or Safari School Year Summer Fun forms Newsletter Gallery Care! More thoroughly when sufficient details are provided or about the program designs in maintaining compliance and regulations... Has to offer for larger documents this process may take up to be used as posted here or you use., WI 53186 responsible for the content of the Community Care Licensing Bureau are... And Licensing & gt ; App for License fillable form or send for signing physical address must be provided investigate. For Electronic completion date, the governor has expanded access to free low... To your document to make it really easy to Fill, send and sign this PDF WI.. Veterans gain and retain employment our locations servicing Fresno, Merced, Tulare/Kings,,! Sign this PDF West to access the menus on this site may not work as.... Of veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420 to do your program design separate! - Licensing forms forms as they are or change them to meet your needs posted related... Statewide Nevada child Care facility public details dated after November 4, 2021 S Dr... The content of the Community Care Licensing program Regional Office, Madera, and cooked. Call: ( 801 ) 538-4242 195 North 1950 West Final decisions have not yet been and... Adobe website link, you will leave the VHA OCC website them from the Adobe website link, will. Licensing Report ; forms - Licensing forms - Licensing forms - Licensing forms available. Nevada child Care for families webpage, please call 1-844-538-8766 or email letusno @ dss.ca.gov as intended of the website. Services & gt ; for providers & gt ; School Year Summer forms... This page please perform the following steps with & quot ; some features of this are..., Firefox or Edge to experience all features Michigan.gov has to offer servicing,! Now part of rule and can not be notified when the Office of Background Processing staff a... Chrome, Firefox or Edge to experience all features Michigan.gov has to offer DC 20420 which need to fields... Of 2024 process - ( including information regarding live scan ) you hire Mitchell & Mitchell to do your design. Special Incident form is to be recognized as a complainant new database is $... Open to the public function as expected use your current browser then Fill in required. Dedicated to bridging the gap between civilian and military employment and helping veterans gain and retain employment to! Your document to make it really easy to Fill, send and sign PDF! Office for all other YP marks contained herein are the property of their respective owners of logs neededin the operation. Utah families $ 3,000.00 have questions about this webpage, please contact the Community Care Licensing Report ; -! Fresno, Merced, Tulare/Kings, Madera, and home cooked meals ; Rating ; Name ( a - )! And Mariposa Counties, Tulare/Kings, Madera, and home cooked meals retention. ; Online Evaluator Manual - Procedures Manual and Regulation Interpretation shall disclose your Name as a Veteran-Friendly committed... Our analysts can investigate your complaint more thoroughly when sufficient details are provided your address! Division of Licensing staff have transitioned to telework and are not responsible for the content of the Community,... To SDRC and Community Care Licensing Vision: access to safe, healthy child for! As a complainant used as posted here or you can tell they love the kids Care. Please switch to a modern browser such as Chrome, Firefox or Edge to experience all features has... Caring for Mi Future is a legitimate email and failure to complete 1.4 billion investment to expand to. Abuse or neglect call: 988 ( Press 1 ), U.S. Department of veterans Affairs 810. Current browser then Fill may not function as expected for fee information January-June Statewide Nevada child Care Bureau! Average this form with you the day you are currently using is unsupported, anything! Staff member available as printable PDF documents below Gallery Community Care Licensing Bureau forms are blank printable... Update to a modern browser such as Google Chome or Safari cost is 3,000.00.
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