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INSTRUCTIONS: PERSONNEL REPORT - CDSS …

STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. instructions : This form is intended for keeping a current roster of all the facility PERSONNEL , other adults and licensees residing in the facility, PERSONNEL REPORT including backup persons, volunteers and licensee if administrator/director. Show license/certificate number if applicable for specialized staff [ , Social Worker and other consultant(s)]. Show coverage for twenty-four hour supervision in residential facilities.

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

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STATE OF CALIFORNIA – HEALTH AND HUMAN …

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