STATE FORMS

In an effort to assist our members, we have provided a list of required forms and equipment. This list is what is listed on 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 and 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 A Notification 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 and 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 Acknowledge Requirement to Report 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 postings shall be in a location visible to clients:


  • LIC 610 A Emergency 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 and Documentation:

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  • 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)
  • Carbon Monoxide Detector
  • Smoke Detector



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