Applicant Information - LIC 215. Forms on this site are available in several formats. If you are in crisis or having thoughts of suicide, However, most Office of Licensing staff have transitioned to telework and are not physically present in the building. 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. If you cannot determine the physical address of the facility, please call (844) 538-8766 or email 195 North 1950 West Program Updates - these updates provide valuable information for new regulations, policy changes, and useful information for providers. About Search Results. Website (801) 669-5370. 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. You may (California), Regional Early Action Planning Grant Application (REAP) (California), RI-FL020 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State (California), RECERTIFICATION FOR CALFRESH BENEFITS (California), VENDOR APPLICATION DS 1890 (Rev. Remember to include the who, what, when, where, and how regarding the incident. You can tell they love the kids and care about, 3534 S Highland Dr, Salt Lake City, UT 84106. File type: PDF. Complete our forms to check eligibility, report incidents, or assessment worksheets, Our counselors and staff can help you with your requests or concerns. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. General Licensing Requirements. ADA Access: Please contact facility for accessibility information. If known, include the name of the perpetrator, Please include names, dates, witnesses, others who have knowledge of the concern, and any other relevant information. Practice "duck, cover, and hold" earthquake drills under tables or desks no less than four times per year. Take two copies of this form with you the day you are fingerprinted. Applicant Fingerprint Follow-Up Request - LIC 107. We received a lot of applications for the 2022 Compliance Grant and hope to have notifications out by the end of September. resident, or child and their location, such as their room number, classroom, unit, or wing number. Child Care Licensing Program Office 744 P Street, MS: T9-15-48 Sacramento, CA 95814 Phone (916) 651-6040 Fax (916) 651-0531 Northern Regional Offices Assistant Program Administrator, Robert Garza (916) 651-6040, Alt. Child Care Community Organizations Human Services Organizations. Sexual Violence Crisis Line Salt Lake City, Ut 84116, Child Care Licensing Contact Info Select option 2 for Provider Management. Licensing forms are available as printable PDF documents below. We do have staff monitoring the incoming mail on a daily basis in the event that electronic submission is unavailable to you. LIC 624, Unusual Incident/Injury Report. | A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z |, Admission Agreement For Residential Care Facilities For The Elderly LIC 604A, Admission Agreement Guide For Residential Facilities LIC 604, Affidavit Regarding Client/Resident Cash Resources LIC 400, Affidavit Regarding Liability Insurance For Family Child Care Home LIC 282, Annual License Fee Notice County LIC 201F, Applicant Fingerprint Follow-Up Request LIC 107, Application for a Child Care Center License LIC 200A, Application For A Community Care Facility or Residential Care Facility For The Elderly License LIC 200, Application For A Family Child Care Home License LIC 279, Application Instructions for A Facility License LIC 281, Appraisal/Needs And Services Plan LIC 625, Balance Sheet Supplemental Schedule LIC 403A, Centrally Stored Medication And Destruction Record LIC 622, Certificate Of Approval (For Certified Family Homes) LIC 229, Child Abuse Central Index Check For County Licensed Facilities -LIC 198, Child Abuse Central Index Check For State Licensed Facilities LIC 198A, Childs Preadmission Health History Parents Report LIC 702, Civil Penalty Assessment Immediate LIC 421B, Civil Penalty Assessment (Unlicensed Facility) LIC 421A, Civil Penalty Ledger Payment, Reduction, Or Waiver Record LIC 422A, Client/Resident Personal Property And Valuables LIC 621, Confidential Report Not Subject To Public Disclosure Report Of Suspected Dependent Adult/Elder Abuse SOC 341, Consent For Emergency Medical Treatment Child Care Centers Or Family Child Care Homes LIC 627, Consent For Emergency Medical Treatment Childrens Residential Facilities LIC 627B, Consent For Emergency Medical Treatment Adult And Elderly Residential Facilities LIC 627C, Consent To A Medical Examination LIC 627A, Criminal Background Clearance Transfer Request LIC 9182, Criminal Record Statement Adoption Facilitator LIC 508A, Criminal Record Statement Long-Term Ombudsman Program LIC 508B, Current Children In Your Home Application For A Family Child Care Home License LIC 279B, Designation Of Facility Responsibility LIC 308, Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities LIC 610D, Emergency Disaster Plan For Child Care Centers LIC 610, Emergency Disaster Plan For Childrens Residential Facilities (Except Foster Family Homes) LIC 610C, Emergency Disaster Plan For Family Child Care Homes LIC 610A, Emergency Disaster Plan For Residential Care Facilities For The Elderly LIC 610E, Emergency Plan For Foster Family Homes LIC 610B, Financial Information Release And Verification LIC 404, Forms/Records To Keep In Your Family Child Care Home LIC 311D, Foster Family Home Application Instructions LIC 283A, Gastrostomy Tube Care: Physicians Checklist (Child Care Facilities) LIC 701A, Gastrostomy Tube Care Consent/Verification (Child Care Facilities) LIC 701B, Health Screening Report Facility Personnel LIC 503, Identification And Emergency Information LIC 601, Identification And Emergency Information Child Care Centers/Family Child Care Homes LIC 700, License Application And Instructions For Child Care Centers LIC 281A, License Application And Instructions For Family Child Care Homes LIC 279A, Notice Of Operation In Violation Of Law LIC 195, Notice Of Operation In Violation Of Law Family Child Care Home LIC 195A, Notification Of Incomplete Application LIC 184, Notification Of Incomplete Foster Family Home Application LIC 184A, Notification Of Initial Application Denial LIC 192, Orientation Meeting Family Child Care Home LIC 186A, Out-Of-State Child Abuse/Neglect Report Request LIC 198B, Out-Of-State Disclosure And Criminal Record Statement LIC 508D, Personal Rights Child Care Centers LIC 613A, Personal Rights Childrens Residential Facilities LIC 613B, Personal Rights Adult Residential Care Facilities LIC 613, Personal Rights Residential Care Facilities for The Elderly (Publicly Operated) LIC 613C, Personal Rights Residential Care Facilities for The Elderly (Privately Operated) LIC 613C-2, Physicians Report Child Care Centers LIC 701, Physicians Report For Community Care Facilities LIC 602, Physicians Report For Residential Care Facilities For The Elderly (RCFE) LIC 602A, Pre-placement Appraisal Information LIC 603, Record Of Clients Cash Resources For Change Of Licensee LIC 424, Record Of Clients/Residents Safeguarded Cash Resources LIC 405, Records To Be Maintained At The Facility Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children LIC 311A, Records To Be Maintained At The Facility Adult Residential LIC 311C, Records To Be Maintained At The Facility Small Family Home And Foster Family Home LIC 311E, Records To Be Maintained At The Facility Residential Care Facility For The Elderly LIC 311F, Records To Be Maintained By The Facility Group Homes LIC 311B, Reference Request Adoption Facilitator LIC 301A, Reference Request Long-Term Care Ombudsman Program LIC 301B, Release Of Client/Resident Medical Information LIC 605A, Removal Confirmation Exemption Needed LIC 300A, Removal Confirmation Non-Exemptible LIC 300D, Removal Confirmation Rescinded LIC 300C, Reporting Requirements By Licensees To The State Department Of Social Services LIC 306, Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders SOC 341a, Supplemental Financial Information LIC 401A, Unusual Incident/Injury Report Family Child Care Home LIC 624B, Your Right To Make Decisions About Medical Treatment PUB 325, If you don't see what you're looking for, please give us a call at 530-894-2114. This is one piece of a historic $1.4 billion investment to expand access to quality, affordable child care for families. 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. This is a legitimate email and failure to complete this registration will result in the grant being cancelled. Submit a written report of the special incident to the regional center within 48 hours (calendar days) of the occurrence of the special incident. This site explains the exemption process. The Word documents are fillable and are intended for electronic completion. Example: resident, family member (e.g., son, daughter, parent), guardian, friend, facility staff, medical professional, neighbor, etc. YP - The Real Yellow PagesSM - helps you find the right local businesses to meet your specific needs. Claim for Payment of Cost of Unauthorized Medical Services, VA Form 10-583 (Fillable PDF) Claim for Miscellaneous Expenses. Forms and documents are available in Adobe Acrobat format for free download. if(responsiveVoice.isPlaying()){ 2021 January-June Statewide Nevada Child Care Licensing Report; Forms - Background. released, or otherwise made publicly available shall disclose your name as a complainant. Claim for Miscellaneous Expenses, VA Form 10-7959e (Fillable PDF) NOTE: This form is not for provider use. Next print the form and then fill in the required responses. Complete this form within 72 hours of calling in a suspicion of abuse or neglect. Group Homes. CCL Mission: To support the child care community by protecting the health and safety of children in child care programs we oversee. Call: (801) 538-4242 The Inspection Checklists are the ones used by licensors . the application book is "LIC 281" Community Care Updates - Quarterly updates on items of interest and program changes you need to know about. Department of Social Services San Jose Childcare 2580 North First Street #300 San Jose, CA 95131 (408)324-2148. Designation Of Administrative Responsibility (Lic 308), Affidavit Regarding Client Cash Resources (Lic 400), Supplemental Financial Information (Lic 401a), Balance Sheet Supplemental Schedule (Lic 403a), Financial Information Release & Verification (Lic404). LIC 702. This document has been signed by all parties. To promote this requirement at your child care center or family care home, you may distribute copies of this flyer (also in Spanish) (PDF). Listed below are samples of forms needed in the day-to-day operation of a licensed Nevada child care facility. The web Browser you are currently using is unsupported, and some features of this site may not work as intended. 3. Application Process: Call or visit website for additional information. From Business: With our experienced staff and innovative programs unlike any other, our commitment to your child's future. 1-800-371-7897 Preferred listings, or those with featured website buttons, indicate YP advertisers who directly provide information about their businesses to help consumers make more informed buying decisions. Transportation Provisions - BCAL-1891, Child Care Center Compliance Record, Part 5. Email: dhslicensing@utah.gov, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities 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. 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. During inspections, licensors will ask to see a government-issued photo ID (or a copy of that ID) for each covered individual. IMPORTANT: You must have Adobe Reader version 6.0 or later installed on your computer to view the documents on this site. Your identity as a complainant is confidential. I can cook,clean,and anything else needed. Sort:Default. Final decisions have not yet been made and contacting CCL staff may delay that decision making process. They treat my kids with respect and teach them great things. this allows you to receive further information from the local licensing office about the status of this complaint. They may be usedas posted here or you can create your own versions. We started out with our oldest at the Riverton location then transferred to the Draper location after our. Our mailing address is: Office of Licensing Human Services License. 07/2011) (Electronic Version) (California). Community Care Licensing Division Child Care Regional Offices . Attention A T users. Multi-Agency State Office Building Hey, thats $39,564.00 a month for 4 clients, $474,768.00 a year. All forms are printable and downloadable. To date, the governor has expanded access to free or low cost child care for 150,000 more kids . The Division of Licensing and Background Checks is comprised of the Office of Licensing and the Office of Background Processing. The CCL website contains regularly updated information on various topics. Community Care Licensing Complaint Form v 1.0, 19-01-CCLD Communication with Complainants FAQs. 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. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. the application book is \"LIC 281\" Community Care Updates - Quarterly updates on items of interest and program changes you need to know about. Love it! Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF Community Care, Inc. - Provider Services1801 Dolphin Drive, Waukesha, WI 53186. Volunteer Certification for Field Trip Transportation CCL-5046 - Word, Playground Inspection Certification Summary CCL-5047 - PDF Salt Lake City, UT 84116. A "Download Fingerprint Form" button will appear after a background check form is authorized. Providers may not make any purchases or begin any installations until the contract is fully executed. To get the most out of Fill, please switch to a free modern browser such as Google Chome or Safari. Spanish. The Application for Certificate of Compliance (HS 633) is used to apply for a license of the following human service programs: This document is locked as it has been sent for signing. Search results are sorted by a combination of factors to give you a set of choices in response to your search criteria. Administrator Certification Program - Information on approved vendors for all facility administrator programs. Mental Health Forms . Salt Lake City, UT 84116, Headquarters You will need to contact the local licensing office for dates and times the administrator exam is given. Listed below are the required forms to be completed by every child care facility owner and employee (age 18 and older) for the required background check per NRS 432A.175. Include the who, what, when, where, and how regarding the incident Playground Inspection Certification CCL-5047... My kids with respect and teach them great things specific needs you day. 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