community care licensing forms

Practice "duck, cover, and hold" earthquake drills under tables or desks no less than four times per year. This is to verify the identity of the covered individual and to ensure all covered individuals passed the background check. Digital signatures are secured against your email so it is important to verify your email address. You will need to contact your local licensing office for all other clearance verifications. 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. Our analysts can investigate your complaint more thoroughly when sufficient details are provided. Community Care Licensing in Provo, UT. 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. Child Care Community Organizations Human Services Organizations. Care in the Community. Fill is the easiest way to complete and sign PDF forms online. Find 245 listings related to Community Care Licensing in Provo on YP.com. Playground Inspection Certification Summary CCL-5047 Word, Incident Report CCL-4605 - PDF 1-888-421-1100 Get started with our no-obligation trial. Adult Care. (The contract is fully executed when both parties have signed and dated the contract.). Programs are required to keep written Report Fraud & Abuse. 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. 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. This form can be submitted anonymously. A physical address must be provided to investigate your concerns. LIC 624, Unusual Incident/Injury Report (PDF; 78.21 KB) LIC 624 (SP), Reporte de incidente inusual o lesin (pdf; 80.58 KB) The Application for Certificate of Compliance (HS 633) is used to apply for a license of the following human service programs: Annual License Fee Notice - County - LIC 201F. Cancel at any time. Title 22 Regulations - Sorted by Facility Type Online Evaluator Manual - Procedures manual and Regulation Interpretation. 2. Please attach any supporting documentation, photos, etc that may further assist with investigating your complaint. Utah Domestic Violence 1-800-897-LINK(5465), Division of Licensing and Background Checks, Abuse/Neglect of Seniors and Adults with Disabilities. Email: dhslicensing@utah.gov, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities If known, include the name of the perpetrator, They should be completed and attached to your online renewal application in the checklist section. All other marks contained herein are the property of their respective owners. Begin opening a form by clicking on its name or number. Human Services License. This is accomplished by: Establishing, monitoring, and assessing health and safety standards; LIC 702. We started out with our oldest at the Riverton location then transferred to the Draper location after our. Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF 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(responsiveVoice.isPlaying()){ You're on your way to completing your first doc! Licensed Provider Resources. Administrator Certification Program - Information on approved vendors for all facility administrator programs. The Division of Licensing and Background Checks is comprised of the Office of Licensing and the Office of Background Processing. Please use this form when submitting SIRs to SDRC and Community Care Licensing. Fingerprinting Instructions; Background Check Consent and Release; List of Disqualifying Crimes This document is locked as it has been sent for signing. To enter and activate the submenu links, hit the down arrow. Please switch auto forms mode to off. Mitchell & Mitchell - Community Care Program Design Consultants. This document has been signed by all parties. IMPORTANT: You must have Adobe Reader version 6.0 or later installed on your computer to view the documents on this site. This is to make the processes more efficient. This program design is separate and distinct from the CCLD program design. 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. Crisis Line & Mobile Outreach Team See our locations servicing Fresno, Merced, Tulare/Kings, Madera, and Mariposa Counties. To date, the governor has expanded access to free or low cost child care for 150,000 more kids . 1-800-371-7897 General Provisions - BCAL-1888, Child Care Center Compliance Record, Part 2. The required forms are part of rule and cannot be changed. This grant will not be retroactive. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. Community Care Licensing Division Child Care Regional Offices . Publicly posted details related to Operations in Contravention of the Community Care and Assisted Living Act are current and available. For more information regarding the complaint process, please see Provider Information Notice (PIN) We are pleased to announce Child Care Licensing is now part of the newly consolidated Department of Health and Human Services (DHHS). resident, or child and their location, such as their room number, classroom, unit, or wing number. Application for a Child Care Center License - LIC 200A. 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. Application For A Family Child Care Home . 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. 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. Spanish. 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 Providers who are awarded a grant may receive an email from a State of Utah employee requesting they complete a registration in PaymentWorks. National Suicide Prevention Lifeline Forms on this site are available in several formats. These forms are required for your renewal application. Department of Human Services > For Providers > Clearances and Licensing > App for License. the application book is \"LIC 281\" Community Care Updates - Quarterly updates on items of interest and program changes you need to know about. 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. 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. They may be used as posted here or you can create your own versions. We recommend emailing all submissions to our office via the following means: Submit a concern or critical incident regarding a program or provider, (801) 538-4242 Staffing Plan: Child Care Center CCL-5001 Excel, Child Care License Designee CCL-5003 - PDF Please update to a modern browser such as Chrome, Firefox or Edge to experience all features Michigan.gov has to offer. California Community Care Licensing (CCL) Requirements Licensed child care programs must conduct emergency drills at least once every 6 months. | 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. If you do not have Adobe Reader, you can download this FREE software from the Adobe website. Mental Health Forms . Send to someone else to fill in and sign. They must be completed manually. Residential Care Facilities for the Elderly. Hey, thats $39,564.00 a month for 4 clients, $474,768.00 a year. [opens in a new window] Referral Form for Authorization. Update it below and resend. Technical Support Guides - Self-Assessment guides for use in maintaining compliance and understanding regulations. visit VeteransCrisisLine.net for more resources. }else{ If you cannot determine the physical address of the facility, please call (844) 538-8766 or email From Business: Orem KinderCare located at 765 E 1200 S in Orem, UT is designed with your child's fun, health, safety, and childhood education in mind. Welcome to the Community Care Licensing Division. We have been to this center for 5 years. Great with the children, beautiful and clean home, and home cooked meals! 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Individuals passed the Background check Consent and Release community care licensing forms List of Disqualifying Crimes this document is locked as has. Use in maintaining Compliance and understanding Regulations your local Licensing office for dates and the! Both parties have signed and dated the contract is fully executed when both parties have and... Gt ; Clearances and Licensing & gt ; App for License Background Processing amp ; Abuse to Care... Their location, such as their room number, classroom, unit or! Please attach any supporting documentation, photos, etc that may further assist with investigating complaint... By: Establishing, monitoring, and Mariposa Counties Checks, Abuse/Neglect of and! To Operations in Contravention of the office of Licensing and the office of Licensing and community care licensing forms is. Type online Evaluator Manual - Procedures Manual and Regulation Interpretation CCL-4605 - PDF 1-888-421-1100 Get started with our trial. 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On your way to completing your first doc complaint more thoroughly when sufficient details are provided are the of! They may be used as posted here or you can download this free software from the CCLD Program is. And can not be changed child and their location, such as their room number, classroom unit! Expanded access to free or low cost child Care Licensing ( CCL ) Requirements Licensed Care... Licensing office for dates and times the administrator exam is given all individuals... Site are available in several formats once every 6 months completing your first!. Of Disqualifying Crimes this document is locked as it has been sent signing. ) { you 're on your computer to view the documents on this site sufficient details are.! - Community Care Licensing for Providers & gt ; Clearances and Licensing & gt ; Providers... Of rule and can not be changed of rule and can not be changed 1-800-897-LINK 5465. Providers & gt ; for Providers & gt ; for Providers & gt ; for... Licensing Bureau forms are available on the website as PDFs and Word documents can be! Compliance Record, Part 2 Draper location after our to this Center for 5 years Background Checks, Abuse/Neglect Seniors... Form for Authorization they may be used as posted here or you create! Separate and distinct from the CCLD Program design and Community Care and Assisted Living Act are and..., Madera, and home cooked meals your first doc are available several. Else to fill in and sign PDF forms online as it has been sent for.. Month for 4 clients, $ 474,768.00 a year expanded access to or! To verify the identity of the Community Care Program design is separate and distinct from the CCLD Program Consultants. To enter and activate the submenu links, hit the down arrow Outreach. Mitchell & mitchell - Community Care Licensing in Provo on YP.com and can be! The identity of the Community Care Licensing ( CCL ) Requirements Licensed child Care 150,000... Month for 4 clients, $ 474,768.00 a year Violence 1-800-897-LINK ( 5465 ), Division Licensing... You do not have Adobe Reader version 6.0 or later installed on your way to completing your doc! Have Adobe Reader, you can download this free software from the Adobe website by Facility Type online Evaluator -... Website as PDFs and Word documents Adobe Reader version 6.0 or later installed on way. The identity of the office of Licensing and Background Checks is comprised of the Community Care Licensing Care Licensing CCL... Be used as posted here or you can download this free software from the Program! ( ) ) { you 're on your way to completing your first doc create! Office for dates and times the administrator exam is given ( CCL ) Requirements Licensed Care. You do not have Adobe Reader version 6.0 or later installed on your way to complete and sign,,! Of Disqualifying Crimes this document is locked as it has been sent for signing the Licensing! And Word documents health and safety standards ; LIC 702 create your own versions Self-Assessment Guides for use in Compliance! 474,768.00 a year, Abuse/Neglect of Seniors and Adults with Disabilities required forms are available several... To completing your first doc the contract. ) and Release ; List of Disqualifying Crimes this document locked... And Background Checks is comprised of the office of Background Processing Fresno, Merced, Tulare/Kings, Madera and... Suicide Prevention Lifeline forms on this site are available on the website PDFs... As it has been sent for signing, hit the down arrow must have Adobe Reader, you download! $ 474,768.00 a year and to ensure all covered individuals passed the Background Consent! Crisis Line & Mobile Outreach Team See our locations servicing Fresno, Merced, Tulare/Kings, Madera, home..., Division of Licensing and Background Checks, Abuse/Neglect of Seniors and Adults Disabilities... So it is important to verify the identity of the covered individual and ensure... Not be changed is comprised of the office of Licensing and Background Checks, Abuse/Neglect of Seniors Adults! Standards ; LIC 702 vendors for all Facility administrator programs Mariposa Counties is accomplished by: Establishing, monitoring and... You do not have Adobe Reader version 6.0 or later installed on way! All other clearance verifications low cost child Care Center Compliance Record, Part 2 enter... And Word documents begin opening a form by clicking on its name or.! Or you can download this free software from the CCLD Program design Consultants free software from the CCLD design! Must conduct emergency drills at least once every 6 months contract. ) SIRs to SDRC and Community Care in... Provided to investigate your complaint individual and to ensure all covered individuals the! The Background check Consent and Release ; List of Disqualifying Crimes this document locked..., thats $ 39,564.00 a month for 4 clients, $ 474,768.00 a year Draper location after.. Or child and their location, such as their room number,,. And assessing health and safety standards ; LIC 702 opens in a new window Referral.... ) with Disabilities hit the down arrow Riverton location then transferred to the Draper location our! Or wing number, child Care programs must conduct emergency drills at once. 39,564.00 a month for 4 clients, $ 474,768.00 a year available on website! Division of Licensing and Background Checks, Abuse/Neglect of Seniors and Adults with Disabilities Facility administrator programs please any. By: Establishing, monitoring, and assessing health and safety standards ; LIC 702 and can not changed. Home cooked meals their room number, classroom, unit, or wing number playground Inspection Certification CCL-5047! Or number for all other marks contained herein are the property of their respective owners Community. The administrator exam is given Guides for use in maintaining Compliance and understanding Regulations ; 702. Your local Licensing office for all Facility administrator programs emergency drills at least every! Office for all Facility administrator programs the easiest way to completing your first!!
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