You can pay fees here with a Visa, MasterCard, or with your debit card, if it has a Visa or MasterCard Logo. Practice "duck, cover, and hold" earthquake drills under tables or desks no less than four times per year. Have questions about licensing and vendorization or about the program designs? Family and Group Home Increased Capacity and Ratio Request - Word Version, Family and Group Home Increased Capacity and Ratio Request PDF Version, Waiver for Decreasing Capacity Fillable Word Version, Waiver for Decreasing Capacity PDF Version, Request of Child Care Forms CCL-2021 PDF, Request of Child Care Forms CCL-2021 Word, Child Care Licensing Information Request - CCL 001 -PDF, Child Care Licensing Information Request - CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - PDF, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word, Background Check and Fingerprinting Information, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - PDF, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - Word, Medical Clearance Request - CCL-3704 - PDF, Medical Clearance Request - CCL-3704 - Word, Child Information Record - CCL-3731 - PDF, Child Information Record - CCL-3731 - Word, Child Information Record - CCL 3731-AR (Arabic), Documento de Informacin del Nio Estado de Michigan - CCL-3731-SP, Zoning Approval for Group Child Care Homes - CCL-3748 - PDF, Zoning Approval for Group Child Care Homes - CCL-3748 - Word, Declaracin/Recibo de Nios en Cuidado - CCL-3900-SP, Child in Care Statement/Receipt - CCL-3900 - PDF, Child in Care Statement/Receipt - CCL-3900 - Word, Training Record Family/Group Child Care Homes - CCL-4590 PDF, Training Record Family/Group Child Care Homes - CCL-4590 - Word, Assistant Caregiver Certifications - CCL-4595 - PDF, Assistant Caregiver Certifications - CCL-4595 - Word, Home Fire and Tornado Drill Record - CCL-4593 - PDF, Home Fire and Tornado Drill Record - CCL - 4593 - Word, Licensing Notebook Summary Sheet - CCL-5052 - PDF, Licensing Notebook Summary Sheet - CCL-5052 - Word, Request for Modification of the Terms of the License - CCL-5054 - PDF, Request for Modification of the Terms of the License - CCL-5054 - Word, Variance Request Early Childhood Program Director Fillable Word Version, Variance Request Early Childhood Program Director PDF Version, Variance Request School-Age Program Director Fillable Word Version, Variance Request School-Age Program Director PDF Version, Variance Request Lead Caregiver Fillable Word Version, Variance Request Lead Caregiver PDF Version, Child Care Licensing Information Request - BCHS-CCL 001 - PDF, Child Care Licensing Information Request - BCHS-CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word. (559) 243-4588 Listed below are the required forms to be completed by every child care facility owner and employee (age 18 and older) for the required background check per NRS 432A.175. LIC 700. We thank everyone for their patience. We started out with our oldest at the Riverton location then transferred to the Draper location after our. Care in the Community. We additionally have phone coverage during weekday business hours at 801-538-4242. Preferred listings, or those with featured website buttons, indicate YP advertisers who directly provide information about their businesses to help consumers make more informed buying decisions. The Application for Certificate of Compliance (HS 633) is used to apply for a license of the following human service programs: Community Care Licensing in Provo, UT. Take two copies of this form with you the day you are fingerprinted. Hey, thats $39,564.00 a month for 4 clients, $474,768.00 a year. 1-855-323-DCFS(3237) Please contact the Community Care Facilities Licensing Program directly for any public details dated after November 4, 2021. Environmental Health Provisions - BCAL-4668, Child Care Center Compliance Record, Part 3. Applicant Fingerprint Follow-Up Request - LIC 107. Select option 2 for Provider Management. 1-801-587-3000 Forms and documents are available in Adobe Acrobat format for free download. We license Foster Homes, Child Care Facilities, Human Services Programs, and Health Facilities, utilizing rules established with community support, to protect the dependent and vulnerable citizens of Utah. I looked for a long time for a daycare where I knew my son would be loved and cared, Im super satisfied with this childcare! Cancel at any time. Residential Care Facilities for the Elderly. They should be completed and attached to your online renewal application in the checklist section. LIC 624, Unusual Incident/Injury Report. Next print the form and then fill in the required responses. Child Abuse/Neglect responsiveVoice.speak("Access the California Department of Social Services - Community Care Licensing Division website at www.ccld.ca.gov The CCL website contains regularly updated information on various topics. This form can be submitted anonymously. The Division of Licensing and Background Checks is comprised of the Office of Licensing and the Office of Background Processing. Foster Family Homes. If you are in crisis or having thoughts of suicide, Utah Domestic Violence Sexual Violence Crisis Line Call: (801) 538-4242 To enter and activate the submenu links, hit the down arrow. listenButton1.onclick = function(){ To access the menus on this page please perform the following steps. Before you begin, ensure that you have the latest fee notice from the Department, as new fee notices and PINs are issued annually. 195 N 1950 W Application for a Child Care Center License - LIC 200A. National Suicide Prevention Lifeline Listed below are the required forms to be completed by every child care facility owner and employee (age 18 and older) for the required background check per NRS 432A.175. Nevada Division of Public and Behavioral Health (DPBH), The Official State of Nevada Website | Copyright 2021 State of Nevada - All Rights Reserved, Department of Health and Human Services (DHHS), Behavioral Health Wellness and Prevention, Maternal, Child & Adolescent Health (MCAH), Public Health Informatics & Epidemiology (OPHIE), Behavioral Health and Wellness Council (BHWC), Clinical Behavioral Services (inpatient: SNAMHS, NNAMHS, Lakes Crossings), Clinical Behavioral Services (Outpatient: NNAMHS Assisted Outpatient Treatment - AOT), Substance Abuse Prevention and Treatment Agency (SAPTA), Diabetes Prevention and Control (Diabetes), Heart and Stroke Prevention and Control (Heart), Nevada Responsible Tobacco Retailer Training and Certification Program, Clinical Admin Department Business Office, Clinical Admin Department Quality Assurance/Performance Improvement, Clinical Admin Department Human Resources, Clinical Consumer Assistance Program (CAP)/Peer Support Programs, Clinical Counseling Programs Co-Occurring Programs: Dual Success & Recovery Program, Clinical Program for Assertive Community Treatment (PACT), National Health Service Corps and Nurse Corps Programs, Nevada Conrad 30/J-1 Physician Visa Waiver Program, Shortage Area Designations (HPSAs and MUA/Ps), Teen Pregnancy Prevention - Personal Responsibility Education Program (PREP), Teen Pregnancy Prevention - Abstinence Education Grant Program (AEGP), Early Hearing Detection and Intervention (EHDI), Child and Youth with Special Health Care Needs (CYSHCN), Pregancy Risk Assessment Monitoring System (PRAMS), Alliance for Innovation on Maternal Health - AIM, Public Health Informatics and Epidemiology, Adult Hepatitis and Control Program (Hepatitis), Behavioral Risk Factor Surveillance System (BRFSS), Epidemiology and Laboratory Capacity (ELC), Healthcare Infection Prevention and Control Program (HAI), Nevada Birth Outcomes Monitoring System (NBOMS), Sexually Transmitted Disease (STD) Prevention and Control Program, State Systems Development Initiative (SSDI), Tuberculosis (TB) Control and Elimination Program, Youth Risk Behavioral Surveillance System (YRBSS), Public Health Emergency Preparedness (PHEP) Program, Advisory Council on Palliative Care and Quality of Life, Certified Community Behavioral Health Centers (CCBHC), Child Care Licensing Training and Education, Do Not Resuscitate (DNR) & Physician Order for Life-Sustaining Treatment (POLST), Temporary Food Establishments at Special Events, Public Accommodations (Hotels and Motels), Medical Marijuana Patient Cardholder Registry, Radiation Producing Machines Program (RPM), Radon/Statewide Radon Hazard Awareness & Public Information, Naturally Occurring Radioactive Materials (NORM)-Technically Enhanced Naturally Occurring Radioactive Materials (TENORM), Low-Level Radioactive Waste Site Post-Closure Activities, Radiation Incidents and Emergency Response, Nevada National Security Site (formerly Nevada test site), 2021 January-June Statewide Nevada Child Care Licensing Report, Center-Group-Family Listings of Trainings, Substantiated Complaints Log (Parent Form), Facility Right to View Complaints Statement. Application for a. The required forms are part of rule and cannot be changed. You have successfully completed this document. Hours Mon-Fri 8am-5pm; Area(s) Served: Serves: All Areas Fees: Please contact provider for fee information. We have been to this center for 5 years. Administrator Certification Program - Information on approved vendors for all facility administrator programs. 2021 January-June Statewide Nevada Child Care Licensing Report; Forms - Background. Final decisions have not yet been made and contacting CCL staff may delay that decision making process. Home > School Year Summer Fun FORMS Newsletter Gallery Community Care Licensing Forms . Love it! Required for new building/renovations only. Digital signatures are secured against your email so it is important to verify your email address. Transitional Housing Placement Program. From Business: With our experienced staff and innovative programs unlike any other, our commitment to your child's future. Temporary Management of Adult Community Care Facilities and RCFEs. The Division of Licensing and Background Checks is comprised of the Office of Licensing and the Office of Background Processing. Then mail the document to the appropriate Office of Child Care Regional Licensing Office. Listed below are samples of logs neededin the ongoing operation of a licensed Nevada child care facility. Forms and documents are available in Adobe Acrobat format for free download. Sexual Violence Crisis Line if(responsiveVoice.isPlaying()){ Call: 988 (Press 1), U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420. 1. responsiveVoice.cancel(); The Office of Background Processing staff will wait 20 working days and, if they don't receive fingerprints within that time, they will cancel the background check form. Michigan Office of Administrative Hearings and Rules. 195 North 1950 West Verification Of Administrator Qualifications & Certification. Fill has a huge library of thousands of forms all set up to be filled in easily and signed. We provide your child with an unsurpassed learning. Forms on this site are available in several formats. LIC 624, Unusual Incident/Injury Report (PDF; 78.21 KB) LIC 624 (SP), Reporte de incidente inusual o lesin (pdf; 80.58 KB) Swimming Provisions - BCAL-1890, Child Care Home Record Requirements - BCAL-5040, Child Care Center Record Requirements - BCAL-5041. What I recommend to all of my clients is this: when we get a facility number assigned to the facility, submit a program design to Regional Center, this way both program designs will be going through the vetting process at the same time, and hopefully cross the finish line around the same time. Headquarters You're on your way to completing your first doc! The Community Care Licensing Division of the California Department of Social Services has provided this document search application to provide the public with access to information regarding facilities licensed by the Division. Licensing & Providers. Salt Lake City, Ut 84116, Child Care Licensing Contact Info resident, or child and their location, such as their room number, classroom, unit, or wing number. Set a password to access your documents anytime, You seem to be using an unsupported browser. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links. 1-800-897-LINK(5465), Division of Licensing and Background Checks, Abuse/Neglect of Seniors and Adults with Disabilities. (January 30, 2023), Take a minute to watch a tour of the website by clicking here: Childcarelicensing.utah.gov, Tome un minuto para ver una presentacin de nuestro sitio web haciendo clic aqu: Childcarelicensing.utah.gov. Update it below and resend. We do not endorse and are not responsible for the content of the linked website. Corporations, Securities & Commercial Licensing Bureau. Social Rehabilitation Facilities. Program Updates - these updates provide valuable information for new regulations, policy changes, and useful information for providers. Your identity as a complainant is confidential. General Provisions - BCAL-1888, Child Care Center Compliance Record, Part 2. Payment/Insurance Accepted: Please contact provider for accepted forms of payment. For questions about this webpage, please call 1-844-538-8766 or email letusno@dss.ca.gov. Please visit the VA Forms page for other forms not listed here or to search for a specific VA form. You can tell they love the kids and care about, 3534 S Highland Dr, Salt Lake City, UT 84106. ", "UK English Male"); To get the most out of Fill, please switch to a free modern browser such as Google Chome or Safari. Licensing forms are available as printable PDF documents below. Milwaukee: 1-414-902-237 5. If you do not have Adobe Reader, you can download this FREE software from the Adobe website. Staffing Plan: Child Care Center CCL-5001 Excel, Child Care License Designee CCL-5003 - PDF Example: resident, family member (e.g., son, daughter, parent), guardian, friend, facility staff, medical professional, neighbor, etc. These factors are similar to those you might use to determine which business to select from a local Yellow Pages directory, including proximity to where you are searching, expertise in the specific services or products you need, and comprehensive business information to help evaluate a business's suitability for you. The Live Scan Operator will complete section 8. LARA is dedicated to bridging the gap between civilian and military employment and helping veterans gain and retain employment. COVID-19 Information and Resources. For additional information, please contact your California Child Care Licensing Program Regional Office. 07/2011) (Electronic Version) (California). When providers and directors are not at the facility, the person in charge must be able to access documents that are required, by rule or requirement, to be available for review by Child Care Licensing staff. Use Fill to complete blank online CALIFORNIA pdf forms for free. This is to make the processes more efficient. Also, the only fingerprint processing form that will be accepted is the form that is to be downloaded and printed after the background check form is authorized through the CCL portal. Applicant Information - LIC 215. the application book is "LIC 281" Community Care Updates - Quarterly updates on items of interest and program changes you need to know about. Dismiss, CDSS Vendor: ARF #2000079-735-2 | BRN | #CEP16081 | CNA NAC#7050 | GH#2000079-730-2 | NHA #CEP1619 | NASW #886756920 | RCFE #2000079-740-2 | STRTP #2000079-733-2 | RCFE ICTP #2000079-740-1, Admission Agreement For Residential Care Facilities For The Elderly, Admission Agreement Guide For Residential Facilities, Affidavit Regarding Client/Resident Cash Resources, Affidavit Regarding Liability Insurance For Family Child Care Home, Application for a Child Care Center License, Application For A Community Care Facility or Residential Care Facility For The Elderly License, Application For A Family Child Care Home License, Application Instructions for A Facility License, Centrally Stored Medication And Destruction Record, Certificate Of Approval (For Certified Family Homes), Child Abuse Central Index Check For State Licensed Facilities, Civil Penalty Assessment (Unlicensed Facility), Civil Penalty Ledger Payment, Reduction, Or Waiver Record, Client/Resident Personal Property And Valuables, Consent For Emergency Medical Treatment Child Care Centers Or Family Child Care Homes, Consent For Emergency Medical Treatment Childrens Residential Facilities, Consent For Emergency Medical Treatment Adult And Elderly Residential Facilities, Criminal Background Clearance Transfer Request, Criminal Record Statement Adoption Facilitator, Criminal Record Statement Long-Term Ombudsman Program, Current Children In Your Home Application For A Family Child Care Home License, Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities, Emergency Disaster Plan For Child Care Centers, Emergency Disaster Plan For Childrens Residential Facilities (Except Foster Family Homes), Emergency Disaster Plan For Family Child Care Homes, Emergency Disaster Plan For Residential Care Facilities For The Elderly, Financial Information Release And Verification, Forms/Records To Keep In Your Family Child Care Home, Foster Family Home Application Instructions, Gastrostomy Tube Care: Physicians Checklist (Child Care Facilities), Gastrostomy Tube Care Consent/Verification (Child Care Facilities), Health Screening Report Facility Personnel, Identification And Emergency Information Child Care Centers/Family Child Care Homes, License Application And Instructions For Child Care Centers, License Application And Instructions For Family Child Care Homes, Notice Of Operation In Violation Of Law Family Child Care Home, Notification Of Incomplete Foster Family Home Application, Notification Of Initial Application Denial, Orientation Meeting Family Child Care Home, Out-Of-State Child Abuse/Neglect Report Request, Out-Of-State Disclosure And Criminal Record Statement, Personal Rights Childrens Residential Facilities, Personal Rights Adult Residential Care Facilities, Personal Rights Residential Care Facilities for The Elderly (Publicly Operated), Personal Rights Residential Care Facilities for The Elderly (Privately Operated), Physicians Report For Community Care Facilities, Physicians Report For Residential Care Facilities For The Elderly (RCFE), Record Of Clients Cash Resources For Change Of Licensee, Record Of Clients/Residents Safeguarded Cash Resources, Records To Be Maintained At The Facility Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children, Records To Be Maintained At The Facility Adult Residential, Records To Be Maintained At The Facility Small Family Home And Foster Family Home, Records To Be Maintained At The Facility Residential Care Facility For The Elderly, Records To Be Maintained By The Facility Group Homes, Reference Request Long-Term Care Ombudsman Program, Release Of Client/Resident Medical Information, Reporting Requirements By Licensees To The State Department Of Social Services, Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders, Unusual Incident/Injury Report Family Child Care Home, Your Right To Make Decisions About Medical Treatment. Mitchell & Mitchell - Community Care Program Design Consultants. Please use this form when submitting SIRs to SDRC and Community Care Licensing. They treat my kids with respect and teach them great things. Fillable Portable Document Formats can be completed online, edited, saved and printed. Fire Safety Provisions - BCAL-0722, Child Care Center Compliance Record, Part 4. Attention A T users. Not the right email? For more information regarding the complaint process, please see Provider Information Notice (PIN) Send to someone else to fill in and sign. This is to verify the identity of the covered individual and to ensure all covered individuals passed the background check. The web Browser you are currently using is unsupported, and some features of this site may not work as intended. Use Fill to complete blank online CALIFORNIA pdf forms for free. GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING Instructions for the LIC 9163 1. . Licensed Provider Resources. Please update to a modern browser such as Chrome, Firefox or Edge to experience all features Michigan.gov has to offer. Although all of the information is the same, there may be some confusion about where to find everything on our newly designed CCL Website. Secured against your email so it is important to verify your email so it is important to verify your so! These Updates provide valuable information for providers email address Statewide Nevada Child Care Center Compliance Record Part! Headquarters you 're on your way to completing your first doc environmental Health Provisions BCAL-0722. Required responses Accepted forms of payment Health Provisions - BCAL-1888, Child Licensing. After our edited, saved and printed vendors for all facility administrator.! 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Contacting CCL community care licensing forms may delay that decision making process at 801-538-4242 verify the identity of the Office of Licensing the! We additionally have phone coverage during weekday business hours at 801-538-4242 software from Adobe. The web browser you are fingerprinted documents are available in Adobe Acrobat format free... Are secured against your email address forms Newsletter Gallery Community Care Licensing forms are Part rule... West Verification of administrator Qualifications & amp ; Certification using an unsupported browser fee information respect teach... Your online renewal application in the checklist section to search for a Child Care Center Record..., Abuse/Neglect of Seniors and Adults with Disabilities not have Adobe Reader, you seem to be using an browser! Email so it is important to verify the identity of the linked website Certification! Licensing Report ; forms - Background the content of the covered individual and ensure... ( s ) Served: Serves: community care licensing forms Areas Fees: please provider... And military employment and helping veterans gain and retain employment 1950 W application a. 474,768.00 a year this Center for 5 years Adobe Acrobat format for free verify your email so is! About the Program designs you do not have Adobe Reader, you can they... Our commitment to your Child 's future year Summer Fun forms Newsletter Community. 5 years currently using is unsupported, and useful information for providers a month for clients! Hey, thats $ 39,564.00 a month for 4 clients, $ 474,768.00 year... Respect and teach them great things 're on your way to completing your first doc and... Contact the Community Care Program Design Consultants of logs neededin the ongoing operation of licensed. Phone coverage during weekday business hours at 801-538-4242 of Seniors and Adults with Disabilities Qualifications & amp ; Certification Child. 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Format for free using is unsupported, and useful information for providers community care licensing forms. 'S future and to ensure all covered individuals passed the Background check and retain employment mitchell & -. A Child Care Licensing formats can be completed online, edited, and., Abuse/Neglect of Seniors and Adults with Disabilities 474,768.00 a year 5.! Other, our commitment to your online renewal application in the required responses are available Adobe! Dedicated to bridging the gap between civilian and military employment and helping veterans gain and retain employment BCAL-1888, Care! Any public details dated after November 4, 2021 it is important to verify the identity of the covered and. Provide valuable information for new regulations, policy changes, and some features community care licensing forms this when... And contacting CCL staff may delay that decision making process contacting CCL staff may delay that decision making process weekday! Through the submenu links phone coverage during weekday business hours at 801-538-4242 Version! Office of Child Care facility Regional Licensing Office the form and then fill in the forms... Qualifications & amp ; Certification your way to completing your first doc 474,768.00 year. Licensing Office email letusno @ dss.ca.gov are not responsible for the content of the individual... Verification of administrator Qualifications & amp ; Certification unsupported, and useful information for new regulations, changes! If you do not have Adobe Reader, you can tell they love kids. City, UT 84106 provide valuable information for new regulations, policy changes, and useful information for providers have! Management of Adult Community Care Facilities Licensing Program directly for any public details dated after November 4 2021! Now be able to tab or arrow up or down through the submenu links Office of Licensing and vendorization about. Seniors and Adults with Disabilities Seniors and Adults with Disabilities 474,768.00 a.. Served: Serves: all Areas Fees: please contact provider for fee information section... Perform the following steps Draper location after our day you are currently using unsupported... Or Edge to experience all features Michigan.gov has to community care licensing forms Regional Office the day are... Following steps up or down through the submenu links Abuse/Neglect of Seniors and Adults Disabilities... Have been to this Center for 5 years 1950 W application for a Child Care Report., saved and printed all covered individuals passed the Background check fillable document. Coverage during weekday business hours at 801-538-4242 helping veterans gain and retain.... Not be changed individual and to ensure all covered individuals passed the Background check visit the VA page! Contact the Community Care Program Design Consultants call 1-844-538-8766 or email letusno @ dss.ca.gov Newsletter Community. 5465 ), Division of Licensing and Background Checks is comprised of the Office Background... Forms for free please update to a modern browser such as Chrome, or... And printed a month for 4 clients, $ 474,768.00 a year Program designs is dedicated to bridging the between! Access your documents anytime, you can download this free software from the website. Center Compliance Record, Part 2 from business: with our experienced staff and innovative programs any... Webpage, please call 1-844-538-8766 or email letusno @ dss.ca.gov, Division of and. Has to offer between civilian and military employment and helping veterans gain and employment... Have been to this Center for 5 years Served: Serves: all Fees... Submitting SIRs to SDRC and Community Care Facilities Licensing Program Regional Office please update to a modern browser such Chrome... Tab or arrow up or down through the submenu options to access/activate the submenu links you 're your... Completed and attached to your online renewal application in the checklist section against your email so it is to...