Fillable Application For Home Care Aide Registration (Page 2 of 2) in pdf

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMMUNITY CARE LICENSING DIVISIONHOME

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CARE SERVICES BUREAU

APPLICATION FOR HOME CARE AIDE REGISTRATION INSTRUCTIONS

To become listed on the Home Care Aide Registry, you must complete and mail the attached application (HCS 100) and the Criminal

Record Statement (LIC 508) and a check or money order to the address listed on the top of the application form. You will also need to

complete the LiveScan form (LIC 9163) and submit fingerprints. If you are applying as an Independent Home Care Aide, please contact

the Home Care Services Bureau at (916) 657-3570 to obtain the Home Care Aide Registry facility number for LiveScan fingerprinting.

For the application type, please check the appropriate box.

Print your full legal name and do not use nicknames.

• NOTE: It is recommended you use the name that is on your ID card. If your ID lists your maiden name but you are using a

married name, use the married name as the main name and maiden name as the AKA.

List all other names you have ever used.

• NOTE: This includes aliases such as ‘Beth’ if used as a legal name.

Print your complete residence address.

• NOTE: City names must be spelled out. Abbreviated city names will not be accepted.

Print your complete mailing address, if different than residence address.

• NOTE: Once you are registered, failure to notify the Home Care Registry Program of a change of mailing address within 10

days will result in forfeiture of your registration.

Please list your email address.

Please list your date of birth in MM/DD/YY format.

• NOTE: You must be 18 years of age or older to apply to be listed on the Home Care Aide Registry.

Please list “M” for male or “F” for female.

Print your Social Security Number.

• NOTE: Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code Sections 1798

et seq.) notice is given for the request of your Social Security Number (SSN) on this form. The requested SSN is voluntary;

however, failure to provide the SSN may delay the processing of this form and the criminal record check. The law requires that

you complete a background check (Health and Safety Code Section 1796.24). The Department will create a file concerning

your criminal background check that will contain certain documents, including information that you provide. You have a right to

access certain records containing your personal information maintained by the Department (Civil Code Section 1798 et seq.).

Under the California Public Records Act and the Freedom of Information Act, the Department may have to provide copies of

some of the records in the file to members of the public who ask for them, including newspaper and television reporters.

Print your ID number, which is required.

• NOTE: You must list one of these four IDs: California Driver’s License; California ID card; Permanent Resident Card; or a

numbered, picture ID issued from a state other than California. If the application only has a Social Security Number without

one of these four acceptable IDs, it will be returned.

10. List a daytime and evening telephone number.

Transfer Process

If you are currently licensed by the Community Care Licensing Division, working in a facility/ Home Care Organization licensed by the

Community Care Licensing Division, or registered with the TrustLine Registry Program, you may be eligible to transfer your background

clearance.

11. Please check the appropriate box.

11a. Please list your Personnel Identification number (Per ID).

12. Please check the appropriate box. If you check “YES” fingerprints are not required. Please submit the completed Application for

Home Care Aide Registration (HCS 100), the Criminal Record Statement (LIC 508) along with a photocopy of your ID to the address

listed on the top of the page.

12a. If you check “YES” please enter the TrustLine Registry number or facility number transferring from:

• NOTE: If you have marked “YES” fingerprints are not required.

Home Care Organization Affiliations

13. Please check the appropriate box. If “YES”, list home care organization information in this section. To affiliate to additional home

care organizations, a transfer request may be submitted only after your application has been approved.

• NOTE: Ensure that the Home Care Organization Name and Number listed on the first row matches the Home Care Organization

Name and Number on the LiveScan form.

Signature Block

You must sign and date the application. If your signature or the date is missing, the application will be returned as incomplete.

Have you remembered the following?

Used exactly the same name on the application form (HCS 100) and page one (1) of the Criminal Record Statement (LIC 508)?

Included the appropriate ID number (i.e. California Driver’s License)?

Submitted your fingerprints through Live Scan?

Signed and dated the application?

Included a check or money order as payment of fees?

Completed, signed, and dated the Criminal Record Statement (LIC 508)?

HCS 100 (12/15)

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Application For Home Care Aide Registration Page 2

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