Lic 198A Form – Fill Out and Use This PDF

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
	COMMUNITY CARE LICENSING DIVISION

All persons subject to a background check are also subject to a Child Abuse Central Index (CACI) check, if the facility to which they are associated provides c a r e a n d s u p e r v i s i o n t o c h i l d r e n . T h i s i n c l u d e s a l l c h i l d c a r e c e n t e r s ; fa m i l y c h i l d c a r e h o m e s ;

c h i l d r e n ’s r e s i d e n t i a l h o m e s a n d fa c i l i t i e s ; and adult residential facilities if, through an approved exception or a specialized license, they provide care to a person under age 18.

If the person is submitting fingerprints for a criminal record background check, a request for a check of the CACI will be transmitted to the Department of Justice at the same time.

If a CACI check is required subsequent to a California Depar tment of Social Services (CDSS) processed criminal record background check, it is the licensee’s responsiblity to submit this form and appropriate fees directly to the Depar tment of Justice, P. O. Box 903417, Sacramento, CA 94203-4170.

TYPE OR PRINT INFORMATION

✔ DATE SENT_______________

NAME:

LAST

FIRST

MIDDLE

✔

DATE OF BIRTH — MO., DAY, YEAR

SOCIAL SECURITY NUMBER - SEE PRIVACY STATEMENT ON PAGE 2.

✔

✔

List all other names you have ever used:

MAIDEN NAME:

NAME/AKA:

✔

NAME/AKA:

NAME/AKA:

✔

CURRENT ADDRESS

STREET

CITY

STATE

ZIP CODE

✔

✔

FACILITY TELEPHONE NUMBER ✔

DRIVER'S LICENSE NUMBER ✔

■ MALE

■ FEMALE

✔

FACILITY NUMBER:

________________________________________________________________________________________

✔

FACILITY NAME:

________________________________________________________________________________________

✔

FACILITY ADDRESS:

________________________________________________________________________________________

STREET

CITY

STATE

ZIP CODE

✔PERSONNEL TYPE OPTIONS

	A ■ FACILITY ADMINISTRATOR/DIRECTOR	F ■ CERTIFIED HOME (FFA)		S ■ SPOUSE OF LICENSEE
	C ■ CORPORATION BOARD MEMBER	L ■ LICENSEE/APPLICANT		(Unless included as a
	E ■ EMPLOYEE	N ■ NONCLIENT ADULT RESIDENT		licensee)
				U ■ UNKNOWN
		P ■ PARTNERSHIP MEMBER
	FOR LICENSING OFFICE USE ONLY
		FOR FOLLOW-UP ONLY
	Original Date Sent______________________		Date Re-sent____________________

FOR DEPARTMENT OF JUSTICE USE ONLY

The result of a name search in the Child Abuse Central Index is as follows:

■The subject of the attached report MAY be the same as the subject of your inquiry.

■No record on the above listed person.

■Too many possible matches to identify. See attached listing.

LIC 198A (3/11)

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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 some one in a licensed facility has a crminal 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 198A (3/11)

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