STATE FORMS

LIC 311 D 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 site and ours for updates.

Children’s Forms/Records


LIC 9224 Acknowledgment of Receipt of Licensing Reports 





LIC 9150Additional Children in Care





LIC 282 Affidavit Regarding Liability Insurance 





LIC 995 E Caregiver Background Check Process





LIC 702 Children’s Pre-Admission Health History 





LIC 627 Consent for Medical Treatment





LIC 9221 Consent for Administration of Medications





LIC 9166Consent/Verification for Nebulizer Care 





LIC 9212 Consumer Awareness Information 





LIC 700 Identification and Emergency Form 





LIC 995 ANotification of Parent’s Rights 





LIC 995 B Notification of Parent’s Rights Remove/Exclude 





LIC 995 C Notification of Parent’s Rights Reinstatement 





PM 286 B California School Immunization Card 





LIC 624 B Unusual Incident/Injury Report





Facility Forms/Records





Personnel Records per Title 22, Div. 12, Ch. 3, Section 102416.1





LIC 9040 Child Care Roster 





LIC 9052 Notice of Employee Rights 





LIC 8572 Report Suspected Child Abuse 





LIC 9108 Acknow Req to Rpt Suspected Child Abuse 





LIC 9149 Property Owner/Landlord Consent Form





LIC 9151 Property Owner/Landlord Notification Form
 




Information to be Posted in your Facility

ALL posting shall be in a location visible to clients





LIC 610 AEmergency Disaster Plan





LIC 999 A Facility Sketch





LIC 9148 Earthquake Preparedness Checklist 





PUB 394 Notification of Parent’s Rights Poster 





LIC 203 Facility License
 




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

LIC 9163 Live Scan Fingerprint Request 



CPR/First Aid Certification – current



PUB 271 Never Shake A Baby



LIC 9058 Applicant/Licensee Rights (LIC 9058) 08/05



License Addendum – If license states capacities of 8 or 14



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





Guides in other languages can be found here

UNDER CONSTRUCTION