Form Lic 995 – Fill Out and Use This PDF

Updated: Oct 28, 2026

The LIC 995 form, issued by the State of California Health and Human Services Agency, serves as a crucial document for ensuring the awareness of parents' rights within childcare centers. It provides a comprehensive overview of parental entitlements, including the right to enter and inspect the facility without prior notice, file complaints, and access public records of any complaints against the childcare provider. With the goal of transparent communication and safeguarding children's welfare, this document acts as a vital tool for both parents and childcare providers.

To ensure your rights are protected and you are fully informed about your child's care environment, consider filling out the form by clicking the button below.

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Form Lic 995 PDF Details

Understanding the LIC 995 form is essential for every parent or guardian who has their child enrolled in a child care center in California. This document, issued by the California Department of Social Services' Community Care Licensing Division, outlines the comprehensive rights parents and authorized representatives hold concerning the care of their children. These rights include unfettered access to inspect the child care center without prior notice, the ability to file complaints against the facility, and the right to examine reports of licensing visits and substantiated complaints made within the last three years. Moreover, the form protects individuals from discrimination or retaliation when exercising these rights and allows for the request of barring certain parents from visiting or taking a child from the center, with the proper court documentation. Furthermore, it mandates that the child care licensee provides the contact information of the local licensing office, informs parents upon request about any adult with a criminal record exemption associated with the center, and supplies the Caregiver Background Check Process form. It also incorporates a section highlighting the legal limitations on parental access based on behavior that could pose a risk to children in care. Ultimately, the LIC 995 form empowers parents and guardians by ensuring they are fully informed of their rights and the measures in place to safeguard the well-being of their children in child care settings.

Question	Answer
Form Name	Form Lic 995
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	Caregiver, Acknowledgement, california, LICENSING

How to Fill Out Form LIC 995

Form LIC 995 at a glance

What it is: CHILD CARE CENTER NOTIFICATION OF PARENTS' RIGHTS is a form of the California Department of Social Services Community Care Licensing Division.

Who signs: The Parent/Authorized Representative signs on the Signature line.

A filled-in Form LIC 995 example: a parent acknowledges the notification

Form LIC 995 example filled out, example: a parent acknowledges the notification — Dana Sample, a parent of Jamie Sample, acknowledges Form LIC 995 at a child care center. Dana receives the licensing office's name, address and telephone number from the center and enters them, then completes the acknowledgement for the center's file. The picture shows both parts filled in, and its names and figures are sample values.

How to fill out Form LIC 995, box by box

Licensing Office Name, Address and Telephone #

Receive from the licensee the name, address and telephone number of the local licensing office, and enter the Licensing Office Name, Licensing Office Address and Licensing Office Telephone #.

Acknowledgement

The parent/authorized representative has received a copy of the "CHILD CARE CENTER NOTIFICATION OF PARENTS' RIGHTS" and the Caregiver Background Check Process form from the licensee.

After "I, the parent/authorized representative of", enter the name of your child. Enter the Name of Child Care Center.

Enter the Date.

This Acknowledgement must be kept in child's file and a copy of the Notification given to parent/authorized representative.

More rules for Form LIC 995

As a Parent/Authorized Representative, you have the right to the rights the form lists.

Enter and inspect the child care center without advance notice whenever children are in care.

File a complaint against the licensee with the licensing office and review the licensee's public file kept by the licensing office.

Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years.

Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order.

Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office.

Receive, from the licensee, the Caregiver Background Check Process form.

California state law provides that the licensee may deny access to the child care center to a Parent/Authorized Representative if the behavior of the Parent/Authorized Representative poses a risk to children in care.

For the Department of Justice "Registered Sex Offender" database, go to www.meganslaw.ca.gov.

Sources

[1] Form LIC 995 (9/08), Child Care Center Notification of Parents' Rights, California Department of Social Services (the Official source link on this page).