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LIC 9163 - Request for Live Scan Services

STATE OF CALIFORNIA - HEALTH AND HUMAN Services AGENCY CALIFORNIA DEPARTMENT OF SOCIAL Services Request FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING Applicant Submission 7 Employer: (Additional response for Department of Social Services , DMV/C P licensing, and Department of Corporations submissions only) Employer Name Street No Street or PO Box Mail Code (five digit code assigned by OJ) City State Zip Code Agency Telephone No (Optional) 4 Agency Address Set Contributing Agency: Agency authorized to receive criminal history information Mail Code (five-digit code assigned by OJ) Street No Street or PO Box Contact Name (Mandatory for all school submissions) City State Zip Code Contact Telephone No 2 Working Title: (Check one) Adult Resident other than Client Em

Group Home (6 or less children) Group Home 6/child less: Group Home (7 or more) Community Treatment Facility; Group Home more/6 child: Residential Care Facility for the Chronically Ill Residential Care Facilities for the Elderly; Residential Care Facility Elderly: Small Family Home

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Transcription of LIC 9163 - Request for Live Scan Services

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STATEMENT ACKNOWLEDGING REQUIREMENT …

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LIC 9108 (3/05) PAGE 2 OF 2 SIGNATURE DATE WHERE TO CALL IN AND SEND THE WRITTEN ABUSE REPORT Reports of suspected child abuse or neglect must be made to any police department or sheriff's

  Report, Requirements, Testament, Child, Abuse, Suspected, Statement acknowledging requirement, Acknowledging, Abuse report, Suspected child abuse

IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM …

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in-home supportive services (ihss) program health care certification form note: the ihss worker may contact you for additional information or to

  Health, Form, Services, Care, Home, Certifications, In home supportive services, Supportive, Ihss, Health care certification form

IMPORTANT INFORMATION FOR PROSPECTIVE …

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state of california - health and human services agency california department of social services important information for prospective providers about the

  Social, Services, Information, Department, Important, California, Provider, Important information for prospective, Prospective, California department of social services important information for prospective providers

Important Information for the In-Home …

www.cdss.ca.gov

TEMP 3001 (11/15) PAGE 1 of 7 STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES Important Information for the

  Social, Services, Information, Department, Important, California, Home, Important information for the in home, California department of social services important information for the

LICENSE APPLICATION AND INSTRUCTIONS FOR …

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LICENSE APPLICATION AND INSTRUCTIONS FOR FAMILY CHILD CARE HOMES This contains instructions needed to file an application for a Family Child Care Home license, and to gain access to

  Applications, Instructions, License, License application and instructions for

REQUEST FOR LIVE SCAN SERVICE - COMMUNITY …

www.cdss.ca.gov

guidelines for community care licensing (ccld) applicants who use a live scan site (ccld ordoj site) for fingerprinting instructions for the lic 9163

  Live, Request, Scan, Request for live scan, Ccld

STATE OF CALIFORNIA - HEALTH AND HUMAN …

www.cdss.ca.gov

state of california - health and human services agency california department of social services community care licensing division lic 9214 (6/16) page 2 of 2

  Health, Social, Services, Department, Human, Agency, Care, California, California health and human, California health and human services agency california department of social services

STATE OF CALIFORNIA – HEALTH AND HUMAN …

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES . APPLICATION FOR SOCIAL SERVICES . To the Applicant: All sections of this form must be completed.

  Health, Social, Services, Department, Human, California, California department of social services, California health and human services, California health and human

STATEMENT ACKNOWLEDGING REQUIREMENT …

www.cdss.ca.gov

soc 341a (3/15) statement acknowledging requirement to report suspected abuse of dependent adults and elders name position facility note: retain in employee/ volunteer file

  Report, Requirements, Testament, Abuse, Statement acknowledging requirement, Acknowledging, Statement acknowledging requirement to report

STATE OF CALIFORNIA – HEALTH AND HUMAN …

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REPORT OF SUSPECTED DEPENDENT ADULT/ELDER FINANCIAL ABUSE FINANCIAL INSTITUTIONS ONLY GENERAL INSTRUCTIONS PURPOSE OF THE FORM This form is to be used by officers and employees of financial institutions (“mandated reporter(s)”) to report suspected

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