Personnel Report Lic 500 Details

In order to obtain your license, you will need to fill out the Lic 500 form. This document is used to collect all of the necessary information required by the Department of Licensing and Regulatory Affairs (LARA). The form can be completed online or on paper, but be sure to have all of the required documents handy before you start. Once you have filled out the form, be sure to submit it along with your application and fee. Your license should arrive in the mail within a few weeks.

Below are some facts you might want to go over before you begin dealing with the lic 500 form.

QuestionAnswer
Form NameLic 500 Form
Form Length2 pages
Fillable?Yes
Fillable fields547
Avg. time to fill out36 min 38 sec
Other nameslic 500 11 03 public, california lic 500 form, lic 500 form, lic500

Form Preview Example

STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PERSONNEL REPORT

INSTRUCTIONS: This form is intended for keeping a current roster of all the facility personnel, other adults and licensees residing in the facility, including backup persons, volunteers and licensee if administrator/director. Show license/certificate number if applicable for specialized staff [e.g., Social Worker and other consultant(s)]. Show coverage for twenty-four hour supervision in residential facilities. Report any changes in personnel to the licensing agency as required by regulations. Send original to Licensing Agency and retain copy in facility file.

NAME OF FACILITY

FACILITY TYPE

FACILITY NUMBER

PREPARED BY

DATE

A.STAFF SUBJECT TO CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following staff members are subject to a criminal background check pursuant to Sections 1522, 1568.09, 1569.17 and 1596.871 of the Health and Safety Code. A California background clearance or a criminal record exemption shall be obtained prior to employment, residence or initial presence in the facility.

 

DATE

 

 

SPECIFY

 

 

SPECIFY

 

 

SPECIFY

 

NAME

JOB TITLE

DAYS AND HOURS ON DUTY

DAYS AND HOURS ON DUTY

DAYS AND HOURS ON DUTY

EMPL'D

 

 

DAYS

FROM

TO

DAYS

FROM

TO

DAYS

FROM

TO

 

 

 

Licensee/Administrator

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIC 500 (11/03) (PUBLIC)

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B.STAFF EXEMPT FROM CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following are believed exempt from criminal background check requirements pursuant to Sections 1522, 1568.09, 1569.17 and 1596.871 of the Health and Safety Code. The licensee or designated representative shall sign below to verify that he or she believes the indicated persons are exempt from criminal background check requirements pursuant to statute.

Signature ________________________________________________________________________________ Date __________________

NAME

DATE

EMPL'D

JOB TITLE

 

SPECIFY

 

 

SPECIFY

 

 

SPECIFY

 

DAYS AND HOURS ON DUTY

DAYS AND HOURS ON DUTY

DAYS AND HOURS ON DUTY

DAYS

FROM

TO

DAYS

FROM

TO

DAYS

FROM

TO

 

 

 

 

 

 

 

 

 

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