Orange County Child Care Association

Provide, Promote and Support Quality Licensed Family Child Care

State Forms

Maintaining forms and records is an important part of being in compliance with state regulations. Community Care Licensing is no longer mailing out updated forms to licensees. It is therefore the provider’s responsibility to ensure they have the most recent information and forms.

In an effort to assist our members we have provided a list of some of these required forms. This list is an aid to LIC 311D – Forms/Records to Keep in Your Family Child Care Homes. Please make a habit of researching and checking the Department of Social Services (DSS) web sit and ours for updates.

Thank You

What’s New About Us Become a Member Contact Us FREE Referrals General Meetings Calendar of Events Health & Wellness Developmental Resources Safety Contributions State Licensing Forms School Readiness Programs Immunizations Resources & Links Interviews SIDS: Sudden Infant Death Syndrome & SBS: Shaken Baby Syndrome Privacy Policy

DO YOU HAVE THE MOST-UP-TO DATE FORMS? Children’s Forms/Records Acknwldgmnt of Receipt of Licensing Reports (LIC 9224) 08/08 Additional Children in Care (LIC 9150) 08/08 Affidavit Regarding Liability Insurance (LIC 282) 08/08 Caregiver Background Check Process (LIC 995E) 10/09 Children’s Pre-Admission Health History (LIC 702) 08/08 Consent for Medical Treatment (LIC 627) 09/08 Consent for Administration of Medications (LIC 9221) 08/08 Consent/Verification for Nebulizer Care (LIC 9166) 02/01 Consumer Awareness Information (LIC 9212) 10/05 Identification and Emergency Information (LIC 700) 08/08 Notification of Parent’s Rights (LIC 995A) 08/08 Notification of Parent’s Rights Remove/Exclude (LIC 995B) 08/08 Notification of Parent’s Rights Reinstatement (LIC 995C) 08/08 California School Immunization Card (PM 286B) 01/02 Unusual Incident/Injury Report (LIC 624B) 08/08 Facility Forms/Records Personnel Records per Title 22, Div. 12, Ch. 3, Section 102416.1 Child Care Roster (LIC 9040) 10/05 Notice of Employee Rights (LIC 9052) 03/03 Report Suspected Child Abuse (LIC 9108) 03/05 Property Owner/Landlord Consent Form (LIC 9149) 02/05 Property Owner/Landlord Notification Form (LIC 9151) 03/05 Information to be Posted in your Facility ALL posting shall be in a location visible to clients Emergency Disaster Plan (LIC 610A) 06/05 Facility Sketch (LIC 999A) 02/05 Earthquake Preparedness Checklist (LIC 9148) 09/00 Notification of Parent’s Rights Poster (PUB 394) 12/06 Facility License (LIC 203) Cite Visit Postings Title 22, Section 1596.8595 (a) (2) a family day care home shall post a copy of any licensing report pertaining to the facility that documents either a facility visit or a complaint investigation that results in a citation for a violation that, if not corrected, will create a direct and immediate risk to the health, safety, or personal rights of children in care. It shall be posted immediately, adjacent to, the interior side of the main door to the facility and shall remain posted for 30 consecutive days. (b) (2) Posting shall remain during hours when clients are present. Additional Forms/Documentation Live Scan Fingerprint Request (LIC 9163) CPR/First Aid Certification – current Never Shake A Baby (PUB 271) 05/05 Applicant/Licensee Rights (LIC 9058) 08/05 License Addendum – If license states capacities of 8 or 14 Pre-admission Health History (LIC 702) Consent for Admin. Of Medication (LIC 9221) 01/08 Other Items to be Maintained Fire Extinguisher, annually serviced Fire & Disaster Drill Log, Title 22, Section 102417 (9) (A) Guides and Helpful Tools Self-Assessment Guide – English Self-Assessment Guide – Spanish Waivers & Exceptions Guide – English Waivers & Exceptions Guide - Spanish Disaster Planning Guide – English Disaster Planning Guide - Spanish

Updated February 10, 2010 NEW To receive notifications via E-mail from DSS contact: linette.villalobos@dss.ca.gov Request to be added to the DSS Notification Dist. List To access CCL web site go to: http://www.ccld.ca.gov WANT TO BECOME A LICENSED PROVIDER? Click here for an application Need to go on an “inactive” status? Click here for an Request Form Title 22 Regulations Division 12, Chapter 3 (09/28/06) Office of Regulations Development Child Care Advocacy LIC 9223 (03/07) Holly Daasnes Basic Learning Requirements Homeowner’s Associations Landlord and Tenant Issues Zoning Issues for Large Facilities CCL Updates October 2009 CCL Manual Letter Title 22 Updates No. CCL-06-07 Dec. 8, 2006 No. CCL-06-06 Sept. 27, 2006 Common Citations Fingerprinting at age 18 – When a licensed provider has anyone in the household who is 18 years and older, state law requires fingerprinting of that person. The person MUST have reached his/her 18^th birthday before fingerprinting can be done, then within 31 days the processing should be completed and records maintained in your facility files. LIVE SCAN LOCATIONS LIVE SCAN REQUEST FORM Assistant Transfer –Assistants who have a clearance to work in child care for one facility cannot work at another facility without the proper transfer documentation. Email Notification Notifications for members when we post regulation updates and other important information related to family child care. Stay up-to-date To keep up-to-date please Email us with your Email address and advise us if you change your email address. Fire Extinguishers Come to a General Meeting and get your annual servicing done for only $15 (price subject to change) Fire & Disaster Drill Log Do you need a log? Click here for your FREE copy

Orange County Child Care Association

PO Box 26769

Santa Ana, CA 92799

714.893.0390

949.348.6988