Form Lic 281d - Application And Supporting Documentation Checklist - Foster Family Agency Page 6
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7CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
13. PERSONNEL REPORT (LIC 500)
•
All planned employee positions are to be shown on this form. Include days and hours staff will be scheduled for
duty. The licensing agency will review to ensure there is required staff coverage for all hours of operation.
•
The Director/Administrator and any staff hired at the time of the application should be on the form. Other positions
with staff not yet hired must be listed as “to be hired” and designated by position title.
•
The licensing agency will make sure anyone designated as EXEMPT from fingerprinting requirements is appropriate
pursuant to Health and Safety Code Section 1522.
•
Ensure that the reverse side of the LIC 500 is signed by the applicant/licensee or designated representative if there
are exempt personnel at the facility.
•
If the applicant is the licensee of another facility, a separate LIC 500 must also be submitted for each
licensed facility.
•
The licensing agency will NOT accept photocopied signatures on this form.
14. PERSONNEL RECORD (LIC 501)
•
Only those who do not complete a LIC 215 should complete this form.
•
This form is to be signed and submitted to the licensing agency with the application only for the
directors/administrators. All other staff forms are to be kept on file for review at the facility.
•
Verification of education and experience will be done against official transcripts and/or references.
15. HEALTH SCREENING REPORT FACILITY PERSONNEL (LIC 503)
(This form is not required, under certain circumstances, of persons who are adherents of a well-recognized church
relying solely upon prayer or spiritual means of healing. Facilities must, however, present satisfactory evidence to the
licensing agency that individuals are free from any communicable disease. Such evidence shall be a written statement
from a practitioner recognized by this religion for the purpose of healing.)
•
One form each is required for the applicant or designee and administrator.
•
Health screening, at time of application, must be less than one year old.
•
If the applicant has other licensed facilities, or the administrator has worked at another facility with the same
licensee, and there is an exam on file, a new health exam is not required unless there are obvious health problems.
•
The LIC 503 must be signed and dated by a qualified medical professional. The licensing agency will NOT accept
photocopied signatures on this form.
•
There must be a health screening with the TB clearance for the Board President, Chief Executive Officer or person
designated by the board resolution.
•
The Tuberculosis (TB) test portion of the form must be filled out, including result, or a separate test verification
is needed.
16. CRIMINAL RECORD STATEMENT (LIC 508)
•
One form each is required for the applicant or designee and administrator.
17. EMERGENCY DISASTER PLAN (LIC 610C)
•
The plan must show two fire cleared relocation sites away from the facility that are able to accommodate the
number of clients the facility is licensed for.
•
If the property is not currently occupied by the applicant, the use of the relocation site requires authorization from
the agency or person currently in possession. The authorization should be verified in writing.
LIC 281D (1/17) (PUBLIC - OPTIONAL)
PAGE 6 OF 7
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