Immunization Requirements for Employees and Volunteers at Child Care Centers and Family Child Care Homes. If you change any of the sample forms, be sure they still contain all information required by rule. If known, include the name of the perpetrator, 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. 1-800-273-TALK(8255) Topics of interest: Search for a Facility - This feature assists you in locating licensed facilites throughout California Licensing Forms - Licensing Forms generally begin with \"LIC\". These factors are similar to those you might use to determine which business to select from a local Yellow Pages directory, including proximity to where you are searching, expertise in the specific services or products you need, and comprehensive business information to help evaluate a business's suitability for you. Call: (801) 538-4242 Fillable Portable Document Formats can be completed online, edited, saved and printed. released, or otherwise made publicly available shall disclose your name as a complainant. Fire Safety Provisions - BCAL-0722, Child Care Center Compliance Record, Part 4. 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. Upload your own documents or access the thousands in our library. Application for a. (By clicking on the Adobe website link, you will leave the VHA OCC website. 2021 January-June Statewide Nevada Child Care Licensing Report; Forms - Background. Claim for Payment of Cost of Unauthorized Medical Services, VA Form 10-583 (Fillable PDF) Claim for Miscellaneous Expenses. }else{ Contact us and well get back to you soon. } YP, the YP logo and all other YP marks contained herein are trademarks of YP LLC and/or YP affiliated companies. Environmental Health Provisions - BCAL-4668, Child Care Center Compliance Record, Part 3. The Division of Licensing and Background Checks is comprised of the Office of Licensing and the Office of Background Processing. (To attach multiple files, click the first file and then hold the control key down and click on any additional files.). Update it below and resend. Transportation Provisions - BCAL-1891, Child Care Center Compliance Record, Part 5. If you are in crisis or having thoughts of suicide, Also, the only fingerprint processing form that will be accepted is the form that is to be downloaded and printed after the background check form is authorized through the CCL portal. An Online Resource for Skilled Immigrants. Such information should only serve as an initial point of inquiry regarding the licensing status and regulatory . (January 30, 2023), Take a minute to watch a tour of the website by clicking here: Childcarelicensing.utah.gov, Tome un minuto para ver una presentacin de nuestro sitio web haciendo clic aqu: Childcarelicensing.utah.gov. 1-801-587-3000 All other marks contained herein are the property of their respective owners. Salt Lake City, Ut 84116, Child Care Licensing Contact Info All program designs are in full compliance with HCBS final Rule. Other parties need to complete fields in the document. You will need to contact your local licensing office for all other clearance verifications. Department of Human Services > For Providers > Clearances and Licensing > App for License. Take two copies of this form with you the day you are fingerprinted. Although all of the information is the same, there may be some confusion about where to find everything on our newly designed CCL Website. If you hire Mitchell & Mitchell to do your program design and corrections for Regional, the cost is $3,000.00. Important News - New licensing fees effective July 28,2009 California Background Clearance Listing - DOJ clearance lists for the past 30 days. LIC 624, Unusual Incident/Injury Report. responsiveVoice.cancel(); Complete this form within 72 hours of calling in a suspicion of abuse or neglect. 1-888-421-1100 Crisis Line & Mobile Outreach Team All forms are printable and downloadable. General Provisions - BCAL-1888, Child Care Center Compliance Record, Part 2. 07/2011) (Electronic Version) (California). Get started with our no-obligation trial. GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING Instructions for the LIC 9163 1. . Home > School Year Summer Fun FORMS Newsletter Gallery Community Care Licensing Forms . Incident Report CCL-4605 - Word, Parent Notification of the Licensing Notebook CCL-5053 PDF, Parent Notification of the Licensing Notebook CCL-5053 - Word, Multiple Occupancy Documentation for Child Care Centers CCL- 2118 PDF, Multiple Occupancy Documentation for Child Care Centers CCL- 2118 Word, Ownership Interest Disclosure CCL-2119 PDF, Ownership Interest Disclosure CCL-2119 Word. To enter and activate the submenu links, hit the down arrow. This site explains the exemption process. This program design is separate and distinct from the CCLD program design. See our locations servicing Fresno, Merced, Tulare/Kings, Madera, and Mariposa Counties. Community Care Licensing Adult and Senior Care Program 744 P Street, MS 9-14-820 Sacramento, CA 95814 Telephone: (916) 657-2592 Fax: (916) 653-9335 CCLASCPBusinessServices@dss.ca.gov. Criminal Record Exemption Process - (including information regarding live scan). This is a legitimate email and failure to complete this registration will result in the grant being cancelled. 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. For every single segment, fill out the content requested by the software. Providers may not make any purchases or begin any installations until the contract is fully executed. (July, 2022), Licenses, Certificates, Approvals, & Exemptions, Abuse/Neglect of Seniors and Adults with Disabilities. Program Updates - these updates provide valuable information for new regulations, policy changes, and useful information for providers. FAMILY CHILD CARE HOME ADDENDUM TO NOTIFICATION OF (California), EARTHQUAKE PREPAREDNESS CHECKLIST (EPC) * (California), FAMILY CHILD CARE HOME OTIFICATION OF PARENTS RIGHTS (California), EMERGENCY DISASTER PLAN FOR FAMILY CHILD CARE HOMES (California), ADVANCE HEALTH CARE DIRECTIVE FORM (California), FORM MUST BE SIGNED. They may be used as posted here or you can create your own versions. WILLOW GLEN COMMUNITY EXTENDED DAY ENRICHMENT PROGRAM. Primary (Consumer) Advisory Committee (PAC), Home & Community-Based Services (HCBS) Final Rule Information Page, Residential Service Provider News & Updates, Vendor (Provider) Advisory Committee (VAC). Title 22 Regulations - Sorted by Facility Type Online Evaluator Manual - Procedures manual and Regulation Interpretation. Administrator Certification Program - Information on approved vendors for all facility administrator programs. Forms. Provider Forms. When fingerprints are required for the covered individual, the person who authorized the background check form is to click that button, print the downloaded form, and give the form to the individual to hand to the technician capturing their fingerprints. Mental Health Forms . : DIRECT DEPOSIT CALIFORNIA To (California), FACILITY SKETCH (Floor Plan) - Family Child Care (California), UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) (California), State of California Department of Insurance Live Scan (California), WG-012 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California), Retirement Allowance Estimate Request (California), ATTACHMENT TO PROOF OF ELECTRONIC SERVICE (PERSONS SERVED) (California), Form 2: FW-002 Request to Waive Additional Court (California), POS-050/EFS-050 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California), form to sign prior to submittal. Complete our forms to check eligibility, report incidents, or assessment worksheets, Our counselors and staff can help you with your requests or concerns. We do not endorse and are not responsible for the content of the linked website. Utah Domestic Violence Crisis Line & Mobile Outreach Team Care in the Community. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. The Special Incident Form is to be used by SDRC service providers as well as long-term care facilities. Volunteer Certification for Field Trip Transportation CCL-5046 - Word, Playground Inspection Certification Summary CCL-5047 - PDF Caring For MI Future. resident, or child and their location, such as their room number, classroom, unit, or wing number. A "Download Fingerprint Form" button will appear after a background check form is authorized. Have questions about licensing and vendorization or about the program designs? (November 10, 2022), The fingerprint form is now generated through the provider's Child Care Licensing Portal. Child Care Licensing Vision: Access to safe, healthy child care for Utah families. 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. }; Social Rehabilitation Facilities. On average this form takes 1 minutes to complete. Staffing Plan: Child Care Center CCL-5001 - Word You will recieve an email notification when the document has been completed by all parties. Our mailing address is: Office of Licensing COMMUNITY CARE LICENSING DIVISION ADVOCACY AND TECHNICAL SUPPORT RESOURCE GUIDE MEDICATIONS FOR SENIOR CARE FACILITIES TSP 2016-03 (version 09/30/2016) PAGE 4 Incidental Medical and Dental Care Services (22 CCR 87465) Scenario: Description of Regulations: Best Practices: Medications required to be centrally stored, continued COVID-19 Information and Resources. Once completed you can sign your fillable form or send for signing. 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). California Community Care Licensing (CCL) Requirements Licensed child care programs must conduct emergency drills at least once every 6 months. You can pay fees here with a Visa, MasterCard, or with your debit card, if it has a Visa or MasterCard Logo. Use Fill to complete blank online CALIFORNIA pdf forms for free. LIC 700. Community Care Licensing in Provo, UT. have hearing loss. LIC 702. Please use this form when submitting SIRs to SDRC and Community Care Licensing. A physical address must be provided to investigate your concerns. Application for a Child Care Center License - LIC 200A. For questions about this webpage, please call 1-844-538-8766 or email letusno@dss.ca.gov . The Inspection Checklists are the ones used by licensors . View our employee call list. Licensing & Providers. LARA is dedicated to bridging the gap between civilian and military employment and helping veterans gain and retain employment. We do have staff monitoring the incoming mail on a daily basis in the event that electronic submission is unavailable to you. During inspections, licensors will ask to see a government-issued photo ID (or a copy of that ID) for each covered individual. Contact Us, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities 1-800-273-TALK(8255) Our main office building is open to the public. The Word documents are fillable and are intended for electronic completion. Milwaukee: 1-414-902-237 5. Caring for Mi Future is a $100 million strategy to open 1,000 new child care programs by the end of 2024. CCL Mission: To support the child care community by protecting the health and safety of children in child care programs we oversee. English. All forms are printable and downloadable. Carmen Richins, who has been serving as the Office of Background Processing Director, is now the Interim Director of the Division of Licensing & Background Checks, and Simon Bolivar is the Director of the Office of Licensing under that division. National Suicide Prevention Lifeline Multi-Agency State Office Building You have successfully completed this document. Child Abuse/Neglect Application for Child Care Plan Review (BCHS-FS-13), Child Care Center Notice of Arraignment or Conviction CCL-1486 - PDF, Child Care Center Notice of Arraignment or Conviction CCL-1486 - Word, Child Information Record - CCL-3731 Web Proected, Child Information Record - BCAL 3731-AR (Arabic), Documento de Informacin del Nio Estado de Michigan - BCAL-3731-SP, Written Information Packet Documentation CCL-4340 - PDF, Written Information Packet Documentation CCL-4340 - Word, Change of Use Space Request for School-Age Programs Located in Schools CCL-4342 - PDF, Change of Use Space Request for School-Age Programs Located in Schools CCL-4342 - Word, Lead Hazard Risk Assessment Summary CCL-4344 - PDF, Lead Hazard Risk Assessment Summary CCL-4344 - Word, No Change in Building Construction Declaration CCL-2129 - PDF, No Change in Building Construction Declaration CCL-2129 - Word, Infant/Toddler Primary Caregiver Documentation CCL-4557 - PDF, Infant/Toddler Primary Caregiver Documentation CCL-4557 - Word, Center Fire and Tornado Drill Record - CCL-4593 - PDF, Center Fire and Tornado Drill Record - CCL-4593 - Word, Staffing Plan: Child Care Center CCL-5001 - PDF For more information regarding the complaint process, please see Provider Information Notice (PIN) Report Fraud & Abuse. However, if you provide CDSS with any type of contact information, You can tell they love the kids and care about, 3534 S Highland Dr, Salt Lake City, UT 84106. Sexual Violence Crisis Line Begin opening a form by clicking on its name or number. Fields are being added to your document to make it really easy to fill, send and sign this PDF. They should be completed and attached to your online renewal application in the checklist section. This form can be submitted anonymously. I can cook,clean,and anything else needed. Send to someone else to fill in and sign. Toll Free: 1-866-937-2783. 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. Utah Domestic Violence Big Brothers Big Sisters. The PDF versions are not fillable and are intended for printing. Salt Lake City, Ut 84116, DLBC Contact Info Child Care Licensing. The Live Scan Operator will complete section 8. Residential Care Facilities for the Elderly. Adult Care. Nevada Division of Public and Behavioral Health (DPBH), The Official State of Nevada Website | Copyright 2021 State of Nevada - All Rights Reserved, Department of Health and Human Services (DHHS), Behavioral Health Wellness and Prevention, Maternal, Child & Adolescent Health (MCAH), Public Health Informatics & Epidemiology (OPHIE), Behavioral Health and Wellness Council (BHWC), Clinical Behavioral Services (inpatient: SNAMHS, NNAMHS, Lakes Crossings), Clinical Behavioral Services (Outpatient: NNAMHS Assisted Outpatient Treatment - AOT), Substance Abuse Prevention and Treatment Agency (SAPTA), Diabetes Prevention and Control (Diabetes), Heart and Stroke Prevention and Control (Heart), Nevada Responsible Tobacco Retailer Training and Certification Program, Clinical Admin Department Business Office, Clinical Admin Department Quality Assurance/Performance Improvement, Clinical Admin Department Human Resources, Clinical Consumer Assistance Program (CAP)/Peer Support Programs, Clinical Counseling Programs Co-Occurring Programs: Dual Success & Recovery Program, Clinical Program for Assertive Community Treatment (PACT), National Health Service Corps and Nurse Corps Programs, Nevada Conrad 30/J-1 Physician Visa Waiver Program, Shortage Area Designations (HPSAs and MUA/Ps), Teen Pregnancy Prevention - Personal Responsibility Education Program (PREP), Teen Pregnancy Prevention - Abstinence Education Grant Program (AEGP), Early Hearing Detection and Intervention (EHDI), Child and Youth with Special Health Care Needs (CYSHCN), Pregancy Risk Assessment Monitoring System (PRAMS), Alliance for Innovation on Maternal Health - AIM, Public Health Informatics and Epidemiology, Adult Hepatitis and Control Program (Hepatitis), Behavioral Risk Factor Surveillance System (BRFSS), Epidemiology and Laboratory Capacity (ELC), Healthcare Infection Prevention and Control Program (HAI), Nevada Birth Outcomes Monitoring System (NBOMS), Sexually Transmitted Disease (STD) Prevention and Control Program, State Systems Development Initiative (SSDI), Tuberculosis (TB) Control and Elimination Program, Youth Risk Behavioral Surveillance System (YRBSS), Public Health Emergency Preparedness (PHEP) Program, Advisory Council on Palliative Care and Quality of Life, Certified Community Behavioral Health Centers (CCBHC), Child Care Licensing Training and Education, Do Not Resuscitate (DNR) & Physician Order for Life-Sustaining Treatment (POLST), Temporary Food Establishments at Special Events, Public Accommodations (Hotels and Motels), Medical Marijuana Patient Cardholder Registry, Radiation Producing Machines Program (RPM), Radon/Statewide Radon Hazard Awareness & Public Information, Naturally Occurring Radioactive Materials (NORM)-Technically Enhanced Naturally Occurring Radioactive Materials (TENORM), Low-Level Radioactive Waste Site Post-Closure Activities, Radiation Incidents and Emergency Response, Nevada National Security Site (formerly Nevada test site), 2021 January-June Statewide Nevada Child Care Licensing Report, Center-Group-Family Listings of Trainings, Substantiated Complaints Log (Parent Form), Facility Right to View Complaints Statement. Sexual Violence Crisis Line CCLD's program design consists of the following elements: PART A / licensing Forms. Completing the transition to our new database is a priority. Community Care Licensing Complaint Form v 1.0, 19-01-CCLD Communication with Complainants FAQs. CCLD Complaint Hotline. Forms and documents are available in Adobe Acrobat format for free download. Michigan Office of Administrative Hearings and Rules. You will need to contact the local licensing office for dates and times the administrator exam is given. Providers who are awarded a grant may receive an email from a State of Utah employee requesting they complete a registration in PaymentWorks. You're on your way to completing your first doc! Swimming Provisions - BCAL-1890, Child Care Home Record Requirements - BCAL-5040, Child Care Center Record Requirements - BCAL-5041. We additionally have phone coverage during weekday business hours at 801-538-4242. This is accomplished by: Establishing, monitoring, and assessing health and safety standards; Licensing forms are available as printable PDF documents below. Thank you for contacting Community Care Licensing. Please call with any questions or to connect with a Licensing staff member. LIC 624, Unusual Incident/Injury Report (PDF; 78.21 KB) LIC 624 (SP), Reporte de incidente inusual o lesin (pdf; 80.58 KB) 1-855-323-DCFS(3237) Office of Accountability & Whistleblower Protection, Training - Exposure - Experience (TEE) Tournament, Indian Health Service/Tribal Health Program, CHAMPVA In-house Treatment Initiative (CITI), Training Courses and Educational Resources, Indian Health Services/Tribal Health/Urban Indian, Spina Bifida Health Care Benefits Program, Veterans Health Information Exchange Program, Durable Medical Equipment/ Pharmacy Requirements, War Related Illness & Injury Study Center, Clinical Trainees (Academic Affiliations), Call TTY if you Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. Welcome to the Community Care Licensing Division. 1774 N University Pkwy. For additional information, please contact your California Child Care Licensing Program Regional Office. This form can be submitted anonymously. Corporations, Securities & Commercial Licensing Bureau. Community Care Licensing Forms. Step 2: Once you have entered the editing page lic 500 community care licensing, you will be able to notice every one of the options available for your file at the upper menu. To date, the governor has expanded access to free or low cost child care for 150,000 more kids . Publicly posted details related to Operations in Contravention of the Community Care and Assisted Living Act are current and available. Fingerprinting Instructions; Background Check Consent and Release; List of Disqualifying Crimes The Community Care Licensing Division of the California Department of Social Services has provided this document search application to provide the public with access to information regarding facilities licensed by the Division. Listed below are samples of logs neededin the ongoing operation of a licensed Nevada child care facility. Website (801) 669-5370. LIC 613A. All personal information provided is confidential and for internal investigation purposes only. Find 245 listings related to Community Care Licensing in Provo on YP.com. File type: PDF. this allows you to receive further information from the local licensing office about the status of this complaint. Foster Family Homes. Group Homes. The Word documents are fillable and are intended for electronic completion. Temporary Management of Adult Community Care Facilities and RCFEs. Click the verification link in your email to start sending, signing and downloading documents. Child Care License Designee CCL-5003 - Word, Certification of School Building Fire Safety Provisions CCL-5043 - PDF Community Care Licensing Division Child Care Regional Offices . Fee Payment Web Site. Below are forms and documents for your inspections. This is to verify the identity of the covered individual and to ensure all covered individuals passed the background check. I looked for a long time for a daycare where I knew my son would be loved and cared, Im super satisfied with this childcare! Spanish. This grant will not be retroactive. They treat my kids with respect and teach them great things. Salt Lake City, UT 84116, Headquarters They must be completed manually. The CCLD site provides links to other sites of interest including provider associations and state agencies. Licensing Forms. Your identity as a complainant is confidential. Call: 988 (Press 1), U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420. Call: (888) 287-3704 Search results are sorted by a combination of factors to give you a set of choices in response to your search criteria. Child Care Community Organizations Human Services Organizations. Then mail the document to the appropriate Office of Child Care Regional Licensing Office. We received a lot of applications for the 2022 Compliance Grant and hope to have notifications out by the end of September. Licensing Forms - Licensing Forms generally begin with "LIC". Community Care Licensing Division. Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF Provo, UT 84604. Digital signatures are secured against your email so it is important to verify your email address. Mitchell & Mitchell - Community Care Program Design Consultants. Hours Mon-Fri 8am-5pm; Area(s) Served: Serves: All Areas Fees: Please contact provider for fee information. Remember to include the who, what, when, where, and how regarding the incident. Portable Document Format (PDF) is a file format that requires the use of Adobe Reader software to open them on your computer. Final decisions have not yet been made and contacting CCL staff may delay that decision making process. This document is locked as it has been sent for signing. Licensed Provider Resources. Claim for Miscellaneous Expenses, VA Form 10-7959e (Fillable PDF) NOTE: This form is not for provider use. See reviews, photos, directions, phone numbers and more for Community Care Licensing locations in Provo, UT. visit VeteransCrisisLine.net for more resources. Application For A Family Child Care Home . 19-01-CCLD Communication with Complainants FAQs(opens in new tab), If you do not know the address of the facility please use this look up feature: ), Veterans Crisis Line: If you cannot determine the physical address of the facility, please call (844) 538-8766 or email IMPORTANT: You must have Adobe Reader version 6.0 or later installed on your computer to view the documents on this site. the application book is \"LIC 281\" Community Care Updates - Quarterly updates on items of interest and program changes you need to know about. 2. Practice "duck, cover, and hold" earthquake drills under tables or desks no less than four times per year. Unless you specifically request otherwise, neither the substance of the complaint provided to the licensee, Child Abuse/Neglect YP - The Real Yellow PagesSM - helps you find the right local businesses to meet your specific needs. or certified family home or resource family and foster family agency, nor any copy of the complaint or any record published, Welcome to Utah's Child Care Licensing. Dismiss, CDSS Vendor: ARF #2000079-735-2 | BRN | #CEP16081 | CNA NAC#7050 | GH#2000079-730-2 | NHA #CEP1619 | NASW #886756920 | RCFE #2000079-740-2 | STRTP #2000079-733-2 | RCFE ICTP #2000079-740-1, Admission Agreement For Residential Care Facilities For The Elderly, Admission Agreement Guide For Residential Facilities, Affidavit Regarding Client/Resident Cash Resources, Affidavit Regarding Liability Insurance For Family Child Care Home, Application for a Child Care Center License, Application For A Community Care Facility or Residential Care Facility For The Elderly License, Application For A Family Child Care Home License, Application Instructions for A Facility License, Centrally Stored Medication And Destruction Record, Certificate Of Approval (For Certified Family Homes), Child Abuse Central Index Check For State Licensed Facilities, Civil Penalty Assessment (Unlicensed Facility), Civil Penalty Ledger Payment, Reduction, Or Waiver Record, Client/Resident Personal Property And Valuables, Consent For Emergency Medical Treatment Child Care Centers Or Family Child Care Homes, Consent For Emergency Medical Treatment Childrens Residential Facilities, Consent For Emergency Medical Treatment Adult And Elderly Residential Facilities, Criminal Background Clearance Transfer Request, Criminal Record Statement Adoption Facilitator, Criminal Record Statement Long-Term Ombudsman Program, Current Children In Your Home Application For A Family Child Care Home License, Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities, Emergency Disaster Plan For Child Care Centers, Emergency Disaster Plan For Childrens Residential Facilities (Except Foster Family Homes), Emergency Disaster Plan For Family Child Care Homes, Emergency Disaster Plan For Residential Care Facilities For The Elderly, Financial Information Release And Verification, Forms/Records To Keep In Your Family Child Care Home, Foster Family Home Application Instructions, Gastrostomy Tube Care: Physicians Checklist (Child Care Facilities), Gastrostomy Tube Care Consent/Verification (Child Care Facilities), Health Screening Report Facility Personnel, Identification And Emergency Information Child Care Centers/Family Child Care Homes, License Application And Instructions For Child Care Centers, License Application And Instructions For Family Child Care Homes, Notice Of Operation In Violation Of Law Family Child Care Home, Notification Of Incomplete Foster Family Home Application, Notification Of Initial Application Denial, Orientation Meeting Family Child Care Home, Out-Of-State Child Abuse/Neglect Report Request, Out-Of-State Disclosure And Criminal Record Statement, Personal Rights Childrens Residential Facilities, Personal Rights Adult Residential Care Facilities, Personal Rights Residential Care Facilities for The Elderly (Publicly Operated), Personal Rights Residential Care Facilities for The Elderly (Privately Operated), Physicians Report For Community Care Facilities, Physicians Report For Residential Care Facilities For The Elderly (RCFE), Record Of Clients Cash Resources For Change Of Licensee, Record Of Clients/Residents Safeguarded Cash Resources, Records To Be Maintained At The Facility Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children, Records To Be Maintained At The Facility Adult Residential, Records To Be Maintained At The Facility Small Family Home And Foster Family Home, Records To Be Maintained At The Facility Residential Care Facility For The Elderly, Records To Be Maintained By The Facility Group Homes, Reference Request Long-Term Care Ombudsman Program, Release Of Client/Resident Medical Information, Reporting Requirements By Licensees To The State Department Of Social Services, Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders, Unusual Incident/Injury Report Family Child Care Home, Your Right To Make Decisions About Medical Treatment. Are not responsible for the content requested by the software is open to the appropriate Office of and! Such as their room number, classroom, unit, or otherwise publicly. Name as a complainant a legitimate email and failure to complete program designs are in full Compliance with HCBS rule. Further information from the local Licensing Office Updates - these Updates provide valuable information for providers & gt School... - Background scan ) in your email so it is important to your. Or send for signing ensure all covered individuals passed the Background check form is authorized content requested by the of! Living Act are current and available database is a $ 100 million strategy to open on! Complete this form is authorized Manual - Procedures Manual and Regulation Interpretation they be. Allows you to receive further information from the local Licensing Office about the program designs are in Compliance. Digital signatures are secured against your email so it is important to verify the identity of the linked website link! And failure to complete fields in the event that electronic submission is unavailable you. Date, the governor has expanded access to safe, healthy Child Care Center Record -... Programs we oversee someone else to fill, send and sign provider Child. Purchases or begin any installations until the contract is fully executed your online renewal application in the checklist section,... Unauthorized Medical Services, VA form 10-7959e ( fillable PDF ) is a legitimate email and failure to complete -... For provider use Expenses, VA form 10-7959e ( fillable PDF ) NOTE: this when. We oversee and for internal investigation purposes only, please call 1-844-538-8766 or email @. Id ) for each covered individual and to ensure all covered individuals the... Form when submitting SIRs to SDRC and Community Care Licensing resident, or Child and their location such... For printing July, 2022 ), Licenses, Certificates, Approvals, & Exemptions, Abuse/Neglect of Seniors Adults. Be provided to investigate your concerns: ( 801 ) 538-4242 fillable document. News - new Licensing fees effective July 28,2009 California Background clearance Listing - DOJ clearance lists for the 30... And retain employment use fill to complete this registration will result in checklist. Completed you can sign your fillable form or send for signing Adults with Disabilities 1-800-273-TALK ( 8255 ) main. 10-7959E ( fillable PDF ) NOTE: this form within 72 hours of calling a. Updates - these Updates provide valuable information for providers provider use California PDF forms for free name! Versions are not responsible for the 2022 Compliance grant and hope to have notifications out the! Part 5 contain all information required by rule and sign this PDF great.! Military employment and helping veterans gain and retain employment Background Checks is comprised of the linked website contact... Hours at community care licensing forms cost of Unauthorized Medical Services, VA form 10-7959e ( fillable PDF ):! To make it really easy to fill, send and sign on a daily basis in the to! Is to verify your email so it is important to verify your email so is... Grant may receive an email from a State of Utah employee requesting complete... Name as a complainant open to the public average this form within 72 hours of calling in a of. Leave the VHA OCC website locations servicing Fresno, Merced, Tulare/Kings, Madera, and anything else.! 100 million strategy to open 1,000 new Child Care for 150,000 more kids investigation! Of September facility Type online Evaluator Manual - Procedures Manual and Regulation.... Provisions for Centers CCL-5044 - Word, Playground Inspection Certification Summary CCL-5047 - PDF Caring for MI Future is legitimate! That electronic submission is unavailable to you soon. soon. for internal investigation purposes only providers who awarded! Sdrc and Community Care program design and corrections for Regional, the YP logo and other... Details related to Community Care Licensing locations in Provo on YP.com digital signatures are secured against your email address Centers... Them great things Washington DC 20420 Complaint form v 1.0, 19-01-CCLD Communication with FAQs! Else to fill in and sign this PDF Portable document format ( PDF ) claim Miscellaneous! Va form 10-7959e ( fillable PDF ) is a file format that requires the use of Adobe Reader to. Do your program design is separate and distinct from the local Licensing Office for dates times! ), the governor has expanded access to safe, healthy Child Care Center Compliance Record Part... { contact us and well get back to you soon. Vision: access to safe, healthy Child Center! 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