LIC 500 PDF Details

The main purpose of this form is to maintain a current roster of all staff members, volunteers, consultants, and others associated with the facility, including their work schedule (days and hours on duty), job titles, license/certificate numbers (if applicable), and other relevant information.

The form also emphasizes the requirement for criminal background checks for all staff members under certain sections of the California Health and Safety Code. This is to ensure that individuals working in these sensitive environments have been properly vetted and are suitable for their roles, particularly when dealing with vulnerable populations such as children or the elderly.

Facilities are required to send the original form to the Licensing Agency and retain a copy in the facility's files. Any changes in personnel must be reported to the licensing agency as specified by regulations.

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 fields2
Avg. time to fill out54 sec
Other nameslic 500 pdf, personnel report lic 500, license form 500, lic 500 personnel report form

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)

Page 1 of 2

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

 

 

 

 

 

 

 

 

 

Page 2 of 2

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lic 500 fillable fields to complete

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Note down the required information when you find yourself within the B STAFF EXEMPT FROM CRIMINAL, Signature Date, NAME, DATE EMPLD, JOB TITLE, SPECIFY DAYS AND HOURS ON DUTY FROM, DAYS, SPECIFY DAYS AND HOURS ON DUTY FROM, DAYS, SPECIFY DAYS AND HOURS ON DUTY FROM, and DAYS area.

lic 500 fillable B STAFF EXEMPT FROM CRIMINAL, Signature  Date, NAME, DATE EMPLD, JOB TITLE, SPECIFY DAYS AND HOURS ON DUTY FROM, DAYS, SPECIFY DAYS AND HOURS ON DUTY FROM, DAYS, SPECIFY DAYS AND HOURS ON DUTY FROM, and DAYS fields to complete

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Filling in lic 500 fillable step 4

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