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