Form Lic 9163 Facility Number PDF Details

The LIC 9163 Facility Number form is a crucial document used within the State of California, managed by the Health and Human Services Agency and the California Department of Social Services. Its primary purpose is to facilitate the process for individuals seeking to work, volunteer, or reside in community care licensing facilities to undergo background checks through the Live Scan fingerprinting system. The form is meticulously structured to gather comprehensive applicant information, including personal details and the specific type of community care facility related to the applicant's submission. Categories covered range from home care aides to residential care facilities for the elderly, indicating the broad scope of community care licensing. Additionally, the document facilitates communication between the California Department of Social Services and the Department of Justice by providing pre-printed sections for agency addresses and specific codes for processing. Notably, the form includes sections for entering applicants' identifying information, the facility number, and details concerning the Live Scan transaction, emphasizing the importance of accuracy and transparency in the background check process. Privacy considerations are also addressed, informing applicants about how their social security numbers and other personal data will be used and protected. This comprehensive approach not only streamlines the background check process for community care licensing but also underscores California's commitment to the safety and well-being of individuals in these care environments.

QuestionAnswer
Form NameForm Lic 9163 Facility Number
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namescommunity care licensing form, request for live scan service lic 9163, california lic community care, lic 9163 live scan form

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICES

REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING

Applicant Submission

1

ORI: A0448

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

Working Title: (Check one)

 

 

 

 

 

 

 

 

Adult Resident other than Client

Employee License, Certification, Applicant

Volunteer Home Care Aide

 

 

 

 

 

 

 

 

 

Registry Applicant

3

Authorized Applicant Type - Enter from list on Page 2, “DOJ Abbreviated CCLD Facility/Organization Type ”

 

 

 

 

 

 

 

 

4

Agency Address Set Contributing Agency:

 

 

 

 

 

CA Dept of Social Services

 

 

 

 

 

0 502

 

 

 

 

 

 

 

 

 

 

 

Agency authorized to receive criminal history information

 

 

Mail Code (five-digit code assigned by OJ)

 

PO BOX 94244

 

Mail Station 9-15-62

 

 

 

N/A

Street No

Street or PO Box

 

 

 

Contact Name (Mandatory for all school submissions)

 

Sacramento,

CA

94244-24 0

 

 

(

)

N/A

City

State

Zip Code

 

 

 

 

 

Contact Telephone No

 

 

 

 

 

 

 

 

 

 

5

Applicant Information:

 

 

 

 

 

 

 

 

Name of Applicant: (Please print)_________________________________________________________________________________

LASTFIRSTMI

AKA’s:________________________________________________

 

CDL No _______________________________________

LAST

FIRST

 

 

 

 

 

 

 

 

 

DOB:_________________________ SEX: Male

Female

 

Misc No

BIL -

 

 

 

 

 

 

 

 

 

 

AGENCY BILLING NUMBER (IF APPLICABLE)

HT:__________________________

WT:____________________

 

Misc No :______________________________________

 

 

 

 

 

PERMANENT RESIDENT (i-551), OUT OF STATE DRIVER’S

 

 

 

 

 

LICENSE OR I D

 

 

 

 

 

EYE Color:____________________

HAIR Color:______________

 

Home Address: (All applicants must complete)

POB:_________________________________________________

 

 

 

 

 

 

 

 

 

 

STREET OR PO BOX

 

 

 

 

 

 

 

 

 

 

 

 

 

SOC:_________________________________________________

 

 

 

 

 

 

 

 

(See Privacy Statement on Page 4)

 

 

 

CITY, STATE AND ZIP CODE

 

 

 

 

 

 

 

 

 

 

6 Facility/Organization Number:_______________________________________Level of Service

DOJ

FBI

If resubmission for fingerprint quality (select R2), list Original ATI No ________________________

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)

8

 

 

 

Live Scan Transaction Completed By:______________________________________________

Date__________________________

 

 

Name of Operator

 

 

 

 

 

Transmitting Agency

LSID#

ATI No

Amount Collected/Billed

LIC 9163 (12/15)

PAGE 1 OF 4

GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO

USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING

Instructions for the LIC 91 3

1.Originating Response Indicator (ORI): Preprinted

2.Working Title: Check the appropriate box

3.Authorized Applicant Type: Indicate the facility type where you will be working.

Select your licensed facility type from the left column, and in the right column find its corresponding DOJ abbreviated facility type. Enter the corresponding DOJ abbreviated facility type on this line.

Note: In the following table you may be able to identify yourself with more than one facility type within each category. Please select only one facility type in any category using the facility that you are most associated with on a day-to-day basis.

If this is your applicable facility type

Enter this abbreviated facility type on your application.

 

 

 

CCLD Facility Type by Category

 

DOJ Abbreviated CCLD Facility Type

 

 

 

Home Care Aide

 

Home Care Aide

 

 

 

Home Care Organization

 

Home Care Organization

 

 

 

Adult Day Care Facility

 

 

Adult Day Support Center

 

Adult Day/Resident/Rehab

Adult Residential Facility

 

 

Social Rehabilitation Facility

 

 

 

 

 

Child Care Center

 

 

Infant Center

 

 

Mildly Ill Center

 

Day Care Center more/6 Child

School Age Child Care Center

 

 

 

 

 

Family Child Care Home

 

Family Day Care

 

 

 

Foster Family Agency

 

 

Foster Family / Adoptions Agency

 

Foster Family/Adopt Employment

Foster Family Agency Sub Office

 

 

 

 

 

Foster Family Agency - Certified Home

 

 

Foster Family Home

 

Foster Family Home

 

 

 

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

 

 

Transitional Housing Placement Program

 

Residential Child Care 6/less

 

 

 

LIC 9 63 ( 2/ 5)

PAGE 2 OF 4

. Agency Address Set Contributing Agency:

 

 

 

Agency authorized to receive criminal history information:

 

 

The following information is pre-printed:

 

 

 

Agency: CA Dept of Social Services

Mail Code: 03502

 

 

Street No.: P.O. BOX 94244, M.S. 9-15-62

Contact Name:

N A

 

 

 

 

 

 

City, State, Zip: Sacramento, CA 94244-2430

Contact Telephone No.:

N A

5.Applicant Information: Print your full name (last, first, middle initial).

AKA’s: Other names the applicant has used

CDL No: CA Drivers License or CA ID

DOB: Date of Birth

SEX: Male or Female

MISC No: BIL - Enter the agency billing

 

 

 

number, if applicable

HT: Height

WT: Weight

MISC No.: Enter any other identification numbers

 

 

 

(PERMANENT RESIDENT, OUT OF STATE DRIVER’S LICENSE OR I.D.)

EYE Color: Color of eyes HAIR Color: Color of hair

Home Address: Applicant’s home address

POB: State or Country of Birth

SOC: Social Security Number (optional) (See Privacy Statement on Page 4)

6.Facility Number: Enter the facility number or assigned OCA number (Agency Identifying Number).

Level of Service: Preprinted

Note: If a Child Abuse Central Index (CACI) check is required, it will automatically be completed by DOJ and all applicable fees will be charged. There is no entry necessary on the applicant’s part.

If resubmission for fingerprint quality, list Original Applicant Tracking Information (ATI) No.: If your finger- prints were rejected and this is a resubmission of your prints, enter the original ATI number provided on the reject notice to avoid paying an additional processing fee.

7.Employer: Enter the facility name and address for which you are being printed.

Employer Name:

Enter the facility organization name.

Street No.:

Enter the facility organization address.

Mail Code:

Enter the facility organization mail code (if applicable).

City, State, Zip:

Enter the facility organization city, state and zip.

Agency Telephone No.:

Enter the facility organization phone number.

8.Live Scan Transaction Completed By: This section will be completed by the Live Scan operator.

Take two copies of this form with you the day you are fingerprinted. The Live Scan Operator will complete section 8. One copy will be retained by the Operator and the other you may retain for your records.

LIC 9163 (12 15)

PAGE 3 OF 4

RIVACY STATEMENT

Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code section 1798 et seq.), notice is given for the request of the Social Security Number (SSN) on this form. The California Department of Justice uses a person’s SSN as an identifying number. The requested SSN is voluntary. Failure to provide the SSN may delay the processing of this form and the criminal record check.

In order to be licensed, work at, or be present at, a licensed facility organization, the law requires that you complete a criminal background check. (Health and Safety Code sections 1522, 1568.09, 1569.17 and 1596.871). The Department will create a file concerning your criminal background check that will contain certain documents, including information that you provide. You have the right to access certain records containing your personal information maintained by the Department (Civil Code section 1798 et seq.). Under the California Public Records Act, the Department may have to provide copies of some of the records in the file to members of the public who ask for them, including newspaper and television reporters.

NOTE: IMPORTANT INFORMATION

The Department is required to tell people who ask, including the press, if someone in a licensed facility organization has a criminal record exemption. The Department must also tell people who ask the name of a licensed facility organization that has a licensee, employee, resident, or other person with a criminal record exemption.

If you have any questions about this form, please contact your local licensing regional office.

LIC 9163 (12 15)

PAGE 4 OF 4

How to Edit Form Lic 9163 Facility Number Online for Free

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Step 1: Step one will be to click on the orange "Get Form Now" button.

Step 2: So you should be on the document edit page. You can add, modify, highlight, check, cross, insert or erase areas or words.

For each section, fill out the information required by the application.

lic 9163 spaces to complete

Include the expected information in the HT WT, Misc No, PERMANENT RESIDENT i OUT OF STATE, EYE Color HAIR Color, Home Address All applicants must, POB, SOC, See Privacy Statement on Page, STREET OR PO BOX, CITY STATE AND ZIP CODE, FacilityOrganization NumberLevel, FBI, If resubmission for fingerprint, Employer Additional response for, and Employer Name box.

part 2 to completing lic 9163

Step 3: The moment you select the Done button, the ready document is easily transferable to each of your devices. Or alternatively, it is possible to send it by means of mail.

Step 4: Make sure you remain away from forthcoming difficulties by creating no less than a pair of copies of your file.

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