Lic 279 Form PDF Details

Embarking on the journey of providing family child care involves navigating through various formalities, one of which is filling out the LIC 279 form. This critical document, set forth by the State of California's Health and Human Services Agency and the California Department of Social Services, is the initial step for individuals intending to open a family child care home. It encompasses a range of information, starting with the type of application, whether it's for a new childcare home, a capacity or location change, or an update to existing details. Applicants are required to share personal information, including home and mailing addresses, phone number, and if applicable, previous counties of residence if they haven't lived in their current county for the past two years. Furthermore, the form queries on the applicant's licensing history for any type of child or adult care facility, ensuring all adults in the home are accounted for while highlighting the specifics of the childcare service intended, such as the capacity and ages of children to be served. Additionally, it highlights the responsibilities of the applicant, such as compliance with fire safety and legal regulations, financial stability, notification of changes, and understanding of child abuse reporting protocols. Finally, with a declaration under penalty of perjury, applicants confirm the truthfulness of their submitted information, emphasizing the legal seriousness and commitment required to provide a safe and nurturing environment for children.

QuestionAnswer
Form NameLic 279 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdaycare lic 279, form lic 279, lic 999, lisence 279

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING

APPLICATION FOR A FAMILY CHILD CARE HOME LICENSE

Type or print clearly.

1.

TYPE OF APPLICATION

 

 

■ New Application ■ Capacity Change ■ Location Change

■ Update

AGENCY USE ONLY

NUMBER:

TYPE:

ASSIGN:

2.

APPLICANT(S) First

 

 

Middle

 

Last Name

 

Over 18 Years Old?

 

 

 

 

 

 

 

 

■ Yes

■ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ Yes

■ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ Yes

■ No

 

 

 

 

 

 

 

 

 

 

3a.

YOUR HOME ADDRESS:

CITY

COUNTY

STATE

ZIP

PHONE:

 

 

 

 

 

 

 

 

 

 

 

3b. IF YOU HAVE NOT LIVED IN THIS COUNTY FOR THE PAST TWO YEARS, LIST THE COUNTIES IN WHICH YOU HAVE RESIDED:

4. MAILING ADDRESS (if different):

CITY

STATE

ZIP

EMAIL ADDRESS (NOT REQUIRED)

5.

DIRECTION(S) TO HOME:

6.ARE YOU CURRENTLY, OR HAVE YOU EVER BEEN, LICENSED OR CERTIFIED FOR ANY TYPE OF FACILITY TO CARE FOR CHILDREN OR ADULTS?

■ Yes ■ No ■ Pending

DATE LICENSED/CERTIFIED:

PHONE:

ADDRESS:

 

 

CITY

 

STATE

ZIP

 

 

 

 

 

 

 

TYPE OF LICENSE:

LICENSE #:

 

LICENSING AGENCY:

 

 

 

 

 

 

 

 

7.

OTHER ADULTS IN THE HOME (Not applicant(s)) Do not list the names of persons under 18 years of age

 

 

First Name

Middle

 

Last Name

 

Relationship to You

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

CURRENT CHILDREN IN YOUR HOME (LIC 279B) Click to access

 

 

 

 

 

9.

TYPE OF LICENSE

 

 

 

AGES TO BE SERVED:

 

DAYS & HOURS OPEN:

 

 

 

 

 

 

 

 

■ Small Home (up to 8)

■ Large Home (up to 14)

 

 

 

 

 

10.APPLICANT/LICENSEE RESPONSIBILITY - I/We certify that:

A.I/We live in the home to be licensed.

B.I/We have money to maintain the level of service required by law in a Family Child Care Home.

C.I/We have both a State Fire Marshal approved fire extinguisher (rated 2A, 10B: C) and a smoke detector in operating condition.

D.I/We shall stay current and in compliance with the laws and regulations governing standards for Family Child CareHomes.

E.I/We shall obtain approval from the licensing agency before making changes in our license capacity, or to our home.

F.I/We shall notify the licensing agency when we want to discontinue our license.

G.I/We have informed the property owner, if leased or rented, that we will be operating a Family Child Care Home on the premises. The owner/landlord has been sent the Property Owner/Landlord Notification (LIC 9151).

H.I/We have written consent from the property owner, if leased or rented, when I plan to expand my Small Family Child Care Home capacity from 6 to 8 children, or to expand my Large Family Child Care Home capacity from 12 to 14 children. Property Owner/Landlord Consent Form (LIC 9149).

I.I/We understand the requirements to report known or suspected child abuse (LIC 9108).

11.PERJURY STATEMENT - I/We declare under penalty of perjury that the statements on this application and accompanying attachments are correct to the best of my/our knowledge.

Applicant(s) Signatures

City and County where Signed

Date

Did you remember to: Sign and date all documents in ink and enclose the application/licensing fee?

LIC 279 (2/09)

PAGE 1 OF 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

Need Help Completing The

Application For a Family Child Care Home License?

These are instructions for filling out the Application for a Family Child Care Home License (LIC 279). Match the numbered items on this page with the numbered sections on the Application.

For your information, details on the Application are public information.

1.TYPE APPLICATION - A “New Application” is a request to license both an individual and a home that are not now licensed. A “Capacity Change” is a request to increase the approved number of children in an already licensed home. A “Location Change” is a request by a licensee to obtain a new license when he/she plans to move. An “Update” is, for example, to request a change in your name or phone number.

2.APPLICANTS - The applicants are the persons who will be responsible for providing child care in their own home. All applicants must live in the home to be licensed and must be 18 years of age or older to be licensed to provide child care. A “Yes” check means the applicants are 18 years of age or older.

3a. YOUR HOME ADDRESS - Your home address is the location of the home in which you live and want to provide care. This is the home that the Licensing Agency will inspect to determine whether it meets health and safety standards. PHONE NUMBER--Enter your primary phone number.

3b. LIST OF ADDITIONAL COUNTIES - If you have not lived in this county for two years, list all other counties where you have lived in the past two years.

4.MAILING ADDRESS - If your mailing address is different from the home address, put your mailing address here. If it is the same, write "Same". EMAIL ADDRESS--It is not a required field to complete.

5.DIRECTION(S) TO HOME - Please provide directions to your home. Please attach a sketch or map if possible.

6.LICENSE OR CERTIFICATION STATUS - This is any license or certification issued to any of the applicants for providing care. If you are or have ever been licensed or certified to provide care, or if an application is pending, check the appropriate box and enter the type of license/certification; date licensed/certified; and name, address and phone number of the Licensing Agency. This includes Foster Family Homes and any other license category.

7.OTHER ADULTS IN THE HOME - List all persons (other than yourself) who live in your home, including family members, boarders, or other relatives. Do not list the names of persons under 18 years of age (See #8 below). If needed, you may attach additional pages to list all residents. You do not need to list your spouse if he/she is also an applicant.

8.CURRENT CHILDREN IN YOUR HOME - Complete the form LIC 279B. List the name, date of birth, sex and relationship of each child living in your home. This sheet will be filed in the confidential portion of your facility file.

9.TYPE OF LICENSE - Requirements for homes serving nine or more children are different from homes serving eight or fewer. Please tell us the capacity you plan to serve, the age range, and what days and/or hours you plan to be open.

10.APPLICANT/LICENSEE RESPONSIBILITY - You need to let the Licensing Agency know that you live in the home to be licensed, have enough money to maintain your home, have basic fire protection, will stay current and in compliance with licensing laws and regulations, will obtain approval from the licensing agency whenever you plan to change your license capacity or make changes to your home, and that you understand the child abuse reporting requirements and the notification and consent requirements related to property owners/landlords.

11.PERJURY STATEMENT - Each applicant must sign the application. The signatures should be the same as the names listed on the top of the form. The signature is signed under a perjury oath. This means that you promise that everything you have said in the application is true and correct. If you knowingly make false statements, you have committed the crime of perjury, which may be punishable by imprisonment.

NOTE: IF YOU DO NOT HAVE ENOUGH SPACE, ATTACH ADDITIONAL PAPER.

LIC 279 (2/09)

PAGE 2 OF 2

How to Edit Lic 279 Form Online for Free

Creating documents along with our PDF editor is simpler than most things. To edit daycare lic 279 the form, there is little you should do - basically keep to the actions listed below:

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

Step 2: At this point, you are able to update the daycare lic 279. This multifunctional toolbar will let you add, get rid of, modify, highlight, and also do several other commands to the words and phrases and fields inside the form.

Complete the following sections to complete the template:

stage 1 to filling out lic 999

Complete the FACILITY TO CARE FOR CHILDREN OR, ADDRESS, TYPE OF LICENSE, LICENSE, LICENSING AGENCY, CITY STATE ZIP, PHONE, OTHER ADULTS IN THE HOME Not, First Name, Middle, Last Name, Relationship to You, CURRENT CHILDREN IN YOUR HOME LIC, Small Home up to Large Home up, and APPLICANTLICENSEE RESPONSIBILITY field using the information demanded by the software.

lic 999 FACILITY TO CARE FOR CHILDREN OR, ADDRESS, TYPE OF LICENSE, LICENSE, LICENSING AGENCY, CITY STATE ZIP, PHONE, OTHER ADULTS IN THE HOME Not, First Name, Middle, Last Name, Relationship to You, CURRENT CHILDREN IN YOUR HOME LIC, Small Home up to Large Home up, and APPLICANTLICENSEE RESPONSIBILITY blanks to fill out

You have to include particular information within the space Applicants Signatures, City and County where Signed, Date, LIC, PAGE OF, and Did you remember to Sign and date.

Completing lic 999 step 3

Step 3: As soon as you've clicked the Done button, your document should be readily available transfer to any kind of electronic device or email address you specify.

Step 4: Be certain to remain away from possible problems by making around a couple of copies of the document.

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