for Child Care Centers - California Department of Social ...

1 LIC 281A (1/07)Application BookletforChild CareCentersThis Application Booklet contains forms and instructions needed to filean application for a license for the following: Child CARE Centers infant CARE Centers TODDLER PROGRAMS SCHOOL-AGE Centers Child CARE Centers FOR MILDLY ILL CHILDRENAn application for a license will be accepted if all of Section A and B arecompleted and sent to the following local licensing district office:Community Care Licensing DivisionApplication Booklet forChild Care CentersINTRODUCTION This booklet is intended to help you file an application for a Child carecenter license. Attached are the required forms and instructions for filing the a license can be issued, the licensing agency must review the information you provideto show that you meet the minimum requirements for a A and B* The application is divided into two sections: Section A contains theforms that you must fill out; and Section B describes the additional supportive documentsthat you must complete.

2 Your application cannot be started until all of the forms in Section Aand all of the documents in Section B are completed and sent to your local licensing districtoffice as a complete package. THE APPLICATION FEE IS NON-REFUNDABLE. If the formsor supportive documents are incomplete, the local licensing district office will return the entirepackage to you. Once it receives the completed Section A forms and the required Section Bdocuments, the local licensing district office will accept your application and, within a fewweeks, the Sacramento headquarters office will mail you information about obtainingfingerprint clearances and Child abuse index COMPLETION To prevent delays in the application, make sure that all of thenecessary information is completed, properly signed and dated.

3 Make a photocopy of yourapplication before you give it to the local licensing district office. If you need additional forms,make photocopies of the blank forms in this booklet or contact your local licensing REGULATIONS The regulations that govern the licensing of Child care centersare contained in the California Code of Regulations, Title 22, Division 12. Copies of theregulations are available from your licensing Law Publishers1-800-888-3600*Information Practices Act of 1977: This information is being requested by the California Departmentof Social Services in compliance with Title 22 of Division 12 of the California Code of Regulations andSection et seq.

4 Of the California Health and Safety Code. Submission of this information ismandatory for licensure. The local licensing district office maintains the information. Access to theinformation will be provided unless prohibited by the Information Practices Act. Certain authorized publicand private agencies may have access to the information, including county welfare departments, theDepartment of Justice, regional Centers , the Department of Developmental Services, the Department ofMental Health, and local law FormDescriptionSECTION ALICENSING FORMSS ection A describes the licensing forms that you must submit to the licensing agency as part of yourapplication. The information in Section A is designed to help you prepare, complete and review theforms.

5 Be sure to pay special attention to the information and instructions on each form, to refer to theguidelines for each form, and to thoroughly complete each specific licensing forms that you must complete for Child CareCenter License(LIC 200A) Information(LIC 215) Record Statement(LIC 508) of Facility Responsibility(LIC 308) Organization(LIC 309) Operating Statement(LIC 401) Sheet (LIC 403) Information Releaseand Verification (LIC 404)Identifies applicant(s) and facility for by applicant(s), , individual(s), chief executiveofficer(s) of a corporation, general partners of a partnership, orcontrolling partner(s) in a limited liability applicant(s) to disclose any criminal the person authorized by the licensee to acceptresponsibility for the facility in the licensee s the organization of a corporation, the board of officers,and anyone having a beneficial ownership of 10 percent or morein the corporation.

6 Also required for a partnership, limited liabilitycompany, and public agency estimated gross profit based on income fromchildren s care, less operation of total assets and liabilities to establish equity ofapplicant(s). A credit check may be obtained to verify financialability to operate the facilityProvides financial information that is verified by a bank or otherfinancial institution. (Applicant completes Section 1 only.)Licensing FormDescriptionSECTION ALICENSING FORMS (continued) Report (LIC 500)A11. Health Screening Report Facility Personnel (LIC 503)A12. Emergency Disaster Plan(LIC 610)A13. Earthquake Preparedness Checklist(LIC 9148)A14. Facility Sketch (LIC 999)A15. Local Fire Inspection AuthorityInformation (LIC 9054)Shows all planned employee positions.

7 Includes days andhours staff will be on Personnel Record (LIC 501)To be completed by site director if other than health of applicant(s) and site director to effectivelyperform duties as developed by applicant to enable facility to handle anyemergency that may arise and to protect the safety and well-being of each of earthquake safety measures that must be attached to theEmergency Disaster Plan (LIC 610).Required for all indoor and outdoor space. The front of the formis for a floor plan; the back is for a yard be completed by any applicant who intends to servenonambulatory children or children with disabilities or specialhealth care DocumentDescriptionSECTION BSUPPORTIVE DOCUMENTSS ection B describes the supportive documents that you must submit to the licensing agency as part ofyour application.

8 In addition to the licensing forms required in Section A, you must complete thefollowing supportive Agreement, Articles ofIncorporation or Articles of of Training for of Daily AgreementInformation contained in these documents lets the licensingagency know who is ultimately responsible for which functionsin the from an accredited school/college and referenceletters confirming required be submitted for each of general personnel policies covering the selectionof qualified staff and conditions of employment ( , pre-employment medical report, knowledge of corporalpunishment, etc.)Plan for in-service training for staff that includes proposedtopics, frequency of training, admission policies and procedures, a Child careprogram description, and discipline attachment to the parent handbook.

9 Includes times thatmeals and snacks are served, nap time (if required), and timesof specific include specific information required by the regulations,including a description of basic and optional services, paymentprovisions, modification conditions, refund policy, rights of thelicensing agency, and reasons for DocumentDescriptionSECTION BSUPPORTIVE DOCUMENTS (continued) MenuB10. List of Furniture/Play EquipmentB11. Control of PropertyB12. Bacteriological Analysis of PrivateWater SupplyTimes for serving meals and snacks and a sample menu for of indoor and outdoor play equipment and furniture gearedto ages of children served. Copy of inventory list provided toinsurance agency is be established through proof of ownership (copy of deedor property-tax bill) or copy of the lease or rental drinking water is from a well or other private source, submitevidence of onsite inspection of the source of the water and abacteriological analysis by a local or state health Department orother qualified public or private laboratory.

10 This is necessary toestablish that the water is 200A APPLICATION FOR A Child CARE CENTER LICENSE This form identifies the applicant(s) and the facility for licensure. For specific instructions, please see the back of the form. Make sure the form is filled out completely. Signature(s) must match #1, Applicant(s) Name, unless the application is a corporationor limited liability company. (See below.) If a partnership is applying for a license, all applicants (including each general partner)must sign the application. If a corporation is applying for a license, all persons signing the application must beauthorized to do so by a board resolution. The application must have an original signature(s). The licensing agency will notacceptphotocopied signatures on this form.