Form Lic 9188 PDF Details

The Lic 9188 form, issued by the State of California Health and Human Services Agency and the California Department of Social Services Community Care Licensing Division, serves a critical function in the transfer of active criminal record exemptions between state-licensed facilities. This process enables a licensee or license applicant to request the transfer of an individual’s criminal record exemption to another facility, ensuring that regulatory compliance is maintained to prevent violations and potential civil penalties. It's essential that the department's approval is obtained before the individual starts having contact with clients in the new facility. The requestor must verify the identity of the individual using valid photo identification and, if transferring to a facility that serves children and a Child Abuse Central Index (CACI) check has not previously been done or is outdated, submit a new CACI check directly to the Department of Justice. Notably, this form emphasizes the importance of maintaining legal and regulatory standards within California’s network of care facilities, focusing on safeguarding the well-being of clients and upholding the integrity of care providers. Furthermore, the inclusion of a privacy statement in the form highlights the balance between transparency, privacy, and security, underlining the measures taken to protect individuals' information while complying with state laws and societal expectations.

QuestionAnswer
Form NameForm Lic 9188
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameslic 9188 form, criminal record exemption letter, ca lic 9188, criminal record exemption transfer request form

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING DIVISION

CRIMINAL RECORD EXEMPTION TRANSFER REQUEST

Active criminal record exemptions may be transferred from one state licensed facility to another by a license applicant or licensee. The transfer must be approved by the Department before the individual who is the subject of the transfer has client contact or the facility will be in violation of the law and subject to a $100 civil penalty.

The license applicant or licensee who is seeking the exemption transfer must verify the individual’s identity and include a copy of the person’s driver’s license or a valid photo identification issued by the California Department of Motor Vehicles or by another state or the United States government if the person is not a California resident. Additionally, a Child Abuse Central Index (CACI) check must be submitted if the exemption transfer is to a facility serving children and the individual has not previously submitted a CACI check or the date of the previous CACI inquiry was prior to January 1, 1999. The CACI must be mailed directly to the Department of Justice with the applicable fee.

This form may only be used to request an exemption transfer between state licensed facilities. To request a transfer between county and state licensed facilities, the requesting Licensing Agency must contact their county liaison.

PLEASE TYPE OR PRINT LEGIBLY

DATE:

PLEASE TRANSFER THE CRIMINAL RECORD EXEMPTION FOR:

LAST NAME

FIRST NAME

MIDDLE INITIAL

CA DRIVER’S LICENSE # or ID #:

DOB:

LICENSING INFORMATION SYSTEM ID #:

SSN: (OPTIONAL)

FROM THE FOLLOWING FACILITY:

NAME OF FACILITY:

FACILITY NUMBER:

STREET ADDRESS:

CITYSTATEZIP CODE

 

TO THE FOLLOWING FACILITY:

 

 

 

 

 

 

 

 

 

 

 

NAME OF FACILITY:

 

 

Transferee Association Type

 

 

 

 

 

 

 

 

 

 

■ Facility Administrator

 

 

FACILITY NUMBER:

 

DATE OF EMPLOYMENT:

■ Corporation Board Member

 

 

 

 

 

 

 

 

 

 

■ Employee

 

 

 

 

 

■ Certified Home

 

 

STREET ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

■ Licensee/Applicant

 

 

 

 

 

■ Non-client Adult Resident

 

 

 

 

 

 

 

 

CITY

STATE

ZIP CODE

■ Partnership Member

 

 

 

 

 

 

 

 

 

 

■ Spouse of Licensee

 

 

 

 

 

 

 

I certify I have verified the above individual’s identity and have enclosed a copy

Title (licensee, administrator, director)

 

 

of the individual’s photo I.D.

 

 

 

 

 

Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR DISTRICT OFFICE USE ONLY

 

 

DATE OF EXEMPTION TRANSFER ENTRY:

INITIAL OF PERSON ENTERING TRANSFER:

LIC 9188 (12/07)

FILE IN NEWLY ASSOCIATED FACILITY FILE

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING DIVISION

PRIVACYSTATEMENT

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, 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 has a criminal record exemption. The Department must also tell people who ask the name of a licensed facility 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 9188 (12/07)

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This form will need you to type in specific information; in order to guarantee consistency, take the time to heed the following steps:

1. First of all, while filling in the criminal record exemption, start in the page that has the subsequent blank fields:

fingerprint transfer request form completion process shown (step 1)

2. The third step is to fill in these particular blank fields: STREET ADDRESS, CITY, STATE, ZIP CODE, Facility Administrator, I certify I have verified the, Title licensee administrator, Signature, DATE OF EXEMPTION TRANSFER ENTRY, INITIAL OF PERSON ENTERING TRANSFER, FOR DISTRICT OFFICE USE ONLY, LIC, and FILE IN NEWLY ASSOCIATED FACILITY.

Filling out part 2 of fingerprint transfer request form

You can certainly get it wrong when completing the I certify I have verified the, so ensure that you reread it before you'll finalize the form.

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