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The Lic 500 form is a crucial document used by facilities in California to maintain an accurate and up-to-date roster of personnel and other adults residing within the facility. This form is not just a bureaucratic requirement; it plays a vital role in ensuring the safety and well-being of individuals in care. It includes sections for listing all staff members, backup personnel, volunteers, and licensees, along with their respective job titles and hours of duty. Additionally, the form mandates that specific staff undergo criminal background checks, as stipulated by various sections of the Health and Safety Code. This requirement underscores the importance of safeguarding the vulnerable populations that these facilities serve. Changes in personnel must be reported to the licensing agency, ensuring compliance with state regulations. The completed Lic 500 form should be submitted to the appropriate licensing agency while a copy is retained in the facility's records for reference. By adhering to these guidelines, facilities can foster a safe environment and demonstrate their commitment to quality care.
Dos and Don'ts
When filling out the Lic 500 form, it's important to follow certain guidelines to ensure accuracy and compliance. Here’s a list of things you should and shouldn’t do:
- Do provide accurate information for all staff members, including their job titles and hours on duty.
- Do ensure that all personnel subject to criminal background checks are clearly identified.
- Do keep a copy of the completed form for your facility's records.
- Do report any changes in personnel to the licensing agency promptly.
- Don’t leave any sections blank; every part of the form must be filled out.
- Don’t forget to include the license or certificate number for specialized staff, if applicable.
- Don’t submit the form without verifying that all information is correct and complete.
Document Attributes
| Fact Name | Description |
|---|---|
| Purpose | The LIC 500 form is used to maintain an up-to-date roster of all personnel in a facility, including staff, volunteers, and licensees. |
| Regulatory Basis | This form is governed by Sections 1522, 1568.09, 1569.17, and 1596.871 of the California Health and Safety Code. |
| Criminal Background Checks | Certain staff members must undergo a criminal background check before being employed or residing in the facility. |
| Submission Requirements | Facilities must send the original form to the Licensing Agency and keep a copy on file at the facility. |
| Exempt Staff | Some individuals may be exempt from background checks, as indicated by the licensee's signature on the form. |
| 24-Hour Supervision | The form helps ensure that there is adequate supervision in residential facilities at all times. |
Key takeaways
Filling out the Lic 500 form is an essential task for facilities under the California Department of Social Services. Here are some key takeaways to keep in mind:
- Accurate Roster: Ensure that the form includes a complete and current list of all personnel, including backup staff and volunteers.
- Criminal Background Checks: Be aware that certain staff members must undergo a criminal background check before they can work or reside in the facility.
- Documentation: Retain a copy of the completed Lic 500 form in your facility's records after submitting the original to the licensing agency.
- Timely Updates: Report any changes in personnel to the licensing agency as required by regulations to maintain compliance.
- Exempt Staff: Identify any staff members who may be exempt from criminal background checks and have the licensee or designated representative sign to verify this status.
- Specific Details: Include specific job titles, days, and hours on duty for each staff member to provide a clear overview of personnel coverage.
Other PDF Templates
Payroll Advance Agreement - Employees can submit this form to avoid potential delays in financial support.
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Example - Lic 500 Form
STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY |
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES |
PERSONNEL REPORT
INSTRUCTIONS: This form is intended for keeping a current roster of all the facility personnel, other adults and licensees residing in the facility, including backup persons, volunteers and licensee if administrator/director. Show license/certificate number if applicable for specialized staff [e.g., Social Worker and other consultant(s)]. Show coverage for
NAME OF FACILITY
FACILITY TYPE
FACILITY NUMBER
PREPARED BY
DATE
A.STAFF SUBJECT TO CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following staff members are subject to a criminal background check pursuant to Sections 1522, 1568.09, 1569.17 and 1596.871 of the Health and Safety Code. A California background clearance or a criminal record exemption shall be obtained prior to employment, residence or initial presence in the facility.
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LIC 500 (11/03) (PUBLIC) |
Page 1 of 2 |
B.STAFF EXEMPT FROM CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following are believed exempt from criminal background check requirements pursuant to Sections 1522, 1568.09, 1569.17 and 1596.871 of the Health and Safety Code. The licensee or designated representative shall sign below to verify that he or she believes the indicated persons are exempt from criminal background check requirements pursuant to statute.
Signature ________________________________________________________________________________ Date __________________
NAME
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EMPL'D
JOB TITLE
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Page 2 of 2
Detailed Instructions for Writing Lic 500
Completing the Lic 500 form is an important task for maintaining an accurate personnel roster at your facility. This form collects information about staff members and other individuals associated with the facility, ensuring compliance with state regulations. Follow these steps to fill out the form correctly.
- Begin by entering the NAME OF FACILITY at the top of the form.
- Next, indicate the FACILITY TYPE and FACILITY NUMBER.
- Fill in the PREPARED BY section with your name and the DATE of completion.
- In section A, list all STAFF SUBJECT TO CRIMINAL BACKGROUND CHECK REQUIREMENTS.
- For each staff member, provide the following details:
- NAME
- JOB TITLE
- DAYS AND HOURS ON DUTY
- EMPLOYMENT DATES (DAYS FROM - TO)
- Move to section B, which covers STAFF EXEMPT FROM CRIMINAL BACKGROUND CHECK REQUIREMENTS.
- List the exempt staff members, including their NAME, DATE EMPLOYED, JOB TITLE, and DAYS AND HOURS ON DUTY.
- Have the licensee or designated representative sign and date the verification statement at the bottom of section B.
- Review the form for accuracy before submitting.
- Send the original form to the Licensing Agency and keep a copy in your facility file.
Documents used along the form
The Lic 500 form is a crucial document used by facilities under the California Department of Social Services. It helps maintain an updated roster of personnel, ensuring compliance with regulations regarding criminal background checks. Along with the Lic 500, several other forms and documents are often utilized to support the licensing and operational processes of these facilities. Below is a list of some of these important documents.
- LIC 501 - Personnel Record: This form collects detailed information about each staff member, including qualifications, training, and employment history. It serves as a comprehensive record to verify that all personnel meet the necessary standards for their roles.
- LIC 508 - Criminal Record Statement: Required for all staff, this document allows individuals to disclose any prior criminal convictions. It is essential for ensuring the safety of residents and compliance with state regulations.
- LIC 9099 - Facility Evaluation Report: This report is used by licensing agencies to assess the overall condition of a facility. It includes evaluations of safety, cleanliness, and compliance with operational standards.
- LIC 610 - Emergency Disaster Plan: This document outlines the procedures a facility will follow in case of an emergency, such as natural disasters or other crises. It ensures that staff and residents are prepared for unexpected situations.
- Durable Power of Attorney Form: For effective future planning, consider utilizing the essential Durable Power of Attorney document to ensure your wishes are honored in legal matters.
- LIC 700 - Application for License: This is the initial application form that facilities must complete to obtain a license. It includes essential information about the facility and its operations.
- LIC 400 - Personnel Policies and Procedures: This document provides guidelines for staff conduct and responsibilities. It is crucial for maintaining a professional and safe working environment.
- LIC 9280 - Staff Training Plan: This form outlines the training requirements for staff members, ensuring they are adequately prepared for their roles and responsibilities within the facility.
Each of these documents plays a vital role in the effective management and operation of facilities licensed by the California Department of Social Services. By ensuring all necessary forms are completed and maintained, facilities can provide a safe and compliant environment for their residents.