Form LIC 500 at a glance
What it is: The Personnel Report, LIC 500, is 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.
Who signs: The licensee or designated representative signs.
A filled-in Form LIC 500 example: a licensee lists the facility roster
How to fill out Form LIC 500, box by box
Name of facility, facility type, facility number, prepared by and date
Fill in the NAME OF FACILITY, the FACILITY TYPE, the FACILITY NUMBER, who it was PREPARED BY and the DATE.
Staff subject to criminal background check requirements
The staff members listed 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.
Fill in NAME, DATE EMPL'D, JOB TITLE and, under SPECIFY DAYS AND HOURS ON DUTY, DAYS, FROM and TO.
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 to verify that he or she believes the indicated persons are exempt from criminal background check requirements pursuant to statute.
Sign on the Signature line and write the Date.
More rules for Form LIC 500
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.
Common questions about Form LIC 500
Where do I file it?
Send original to Licensing Agency and retain copy in facility file.
Sources
[1] Form LIC 500 (11/03), California Department of Social Services (the Official source link on this page).
