Lic 508 Form PDF Details

In the landscape of care facilities in California, the LIC 508 form plays a crucial role, serving as a cornerstone document for the California Department of Social Services. This form, mandated by state law, is required for individuals associated with licensed care facilities, applicants to the Home Care Aide Registry, or TrustLine Registry, ensuring they undergo a fingerprint-based background check and disclose any convictions they may have. Notably, the form stipulates exceptions for certain marijuana-related offenses in line with marijuana reform legislation, as well as convictions dismissed under specific sections of the Penal Code. Furthermore, it delves into the necessity of disclosing past convictions, regardless of their nature or the time elapsed since their occurrence, underpinning the importance of transparency in positions of trust. The form also outlines the ramifications of failing to disclose such information, which can lead to severe consequences like exemption denial, application denial, or license revocation. Additionally, the LIC 508 includes provisions for notifying the Caregiver Background Check Bureau of address changes, thereby ensuring that the background checks are up-to-date and reflective of one's current status. Through its comprehensive approach to disclosure and background checks, the LIC 508 form embodies the state's commitment to safeguarding the well-being and safety of individuals in care facilities.

QuestionAnswer
Form NameLic 508 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesform criminal, form 508, criminal record statement lic 508 california form, lic508

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State of California ­– Health and Human Services Agency

California Department of Social Services

CRIMINAL RECORD STATEMENT & OUT-OF-STATE DISCLOSURE

State law requires that persons associated with licensed care facilities, Home Care Aide Registry or TrustLine Registry applicants be fingerprinted and disclose any conviction. A conviction is any plea of guilty or nolo contendere (no contest) or a verdict of guilty. The fingerprints will be used to obtain a copy of any criminal history you may have.

Have you ever been convicted of a crime in California?

n YES n NO

You do not need to disclose any marijuana-related offenses covered by the marijuana reform legislation codified at Health and Safety Code sections 11361.5 and 11361.7.

Have you ever been convicted of a crime from another state, federal court,

 

military, or jurisdiction outside of U.S.?

n YES n NO

You do not need to disclose convictions that were a result of one’s status as a victim of human trafficking and that were dismissed pursuant to Penal Code Section 1203.49, nor any marijuana-related offenses covered by the marijuana reform legislation codified at Health and Safety Code sections 11361.5 and 11361.7. However, you are required to disclose convictions that were dismissed pursuant to Penal Code Section 1203.4(a).

Criminal convictions from another State or Federal court are considered the same as criminal convictions in California.

For Foster Family Homes, Certified Family Homes, and Resource Families only:

 

 

Have you ever been arrested for a crime against a child or for spousal

 

 

or cohabitant abuse?

n YES

n NO

For Children’s Residential Facilities:

 

 

Have you lived in a state other than California within the last five years?

n YES

n NO

If yes, list each state below and then complete an LIC 198B for each state:

 

 

________________________________________________________________________________

________________________________________________________________________________

You must check yes to the corresponding question(s) above to report every conviction (including reckless and drunk driving convictions) you have on your record, even if:

It happened a long time ago;

It was only a misdemeanor;

You didn’t have to go to court (your attorney went for you);

You had no jail time, or the sentence was only a fine or probation;

You received a certificate of rehabilitation; or

The conviction was later dismissed, set aside or the sentence was suspended.

NOTE: IF THE CRIMINAL BACKGROUND CHECK REVEALS ANY CONVICTION(S) THAT YOU DID NOT REPORT ON THIS FORM BY CHECKING YES, YOUR FAILURE TO DISCLOSE THE CONVICTION(S) MAY RESULT IN AN EXEMPTION DENIAL, APPLICATION DENIAL, LICENSE REVOCATION, DECERTIFICATION, RESCISSION OF APPROVAL, OR EXCLUSION FROM A LICENSED FACILITY, CERTIFIED FAMILY HOME, OR THE HOME OF A RESOURCE FAMILY.

LIC 508 (7/20)

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State of California ­– Health and Human Services Agency

California Department of Social Services

 

 

 

 

If you move or change your mailing address, you must send your updated information to the Caregiver Background Check Bureau within 10 days to:

Caregiver Background Check Bureau

744 P Street, M/S T9-15-62

Sacramento, CA 95814

I declare under penalty of perjury under the laws of the State of California that I have read and understand the information contained in this affidavit and that my responses and any accompanying attachments are true and correct.

FACILITY/ORGANIZATION/AGENCY NAME:

FACILITY/ORGANIZATION NUMBER:

YOUR NAME (print clearly):

YOUR ADDRESS (street, city, state, zip):

SOCIAL SECURITY NUMBER: (See Privacy Statement on Page 3):

DRIVER’S LICENSE NUMBER/STATE:

DATE OF BIRTH:

SIGNATURE:

DATE:

Instructions to Licensees:

If the person discloses that they have ever been convicted of a crime, maintain this form in your facility/organization personnel file and send a copy to your Licensed Program Analyst (LPA) or assigned analyst.

Instructions to Regional Offices and Foster Family Agencies:

If ‘Yes’ is indicated in any box above, forward a copy of this completed form (and the LIC 198B, as applicable) to the Caregiver Background Check Bureau, 744 P Street, MS T9-15-62, Sacramento, CA 95814.

If ‘No’ is indicated above in all boxes, keep this completed form in the facility file.

LIC 508 (7/20)

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State of California ­– Health and Human Services Agency

California Department of Social Services

 

 

 

 

PRIVACY STATEMENT

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/organization, the law requires that you complete a criminal background check. (Health and Safety Code sections 1522, 1568.09, 1569.17, 1596.871, and 1796.19). 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

With the exception of Foster Family Homes, Certified Family Homes, Small Family Childcare Homes, and Resource Family Approval Homes, the Department is required to tell people who ask, including the press, if someone in a licensed facility/organization has a criminal record exemption. The Department must also tell people who ask, the name of a licensed facility/organization 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 508 (7/20)

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How to Edit Lic 508 Form Online for Free

Writing the form criminal form is simple with our PDF editor. Stick to the next actions to obtain the document immediately.

Step 1: Search for the button "Get Form Here" on the webpage and press it.

Step 2: Right now, you can start modifying the form criminal. The multifunctional toolbar is at your disposal - add, remove, transform, highlight, and conduct similar commands with the content in the file.

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508 criminal record form fields to fill in

Indicate the details in For Foster Family Homes Certified, For Childrens Residential, n YES n NO, n YES n NO, You must check yes to the, It happened a long time ago It was, and NOTE IF THE CRIMINAL BACKGROUND.

508 criminal record form For Foster Family Homes Certified, For Childrens Residential, n YES n NO, n YES n NO, You must check yes to the, It happened a long time ago It was, and NOTE IF THE CRIMINAL BACKGROUND blanks to complete

The system will require you to put down particular key information to effortlessly complete the part I declare under penalty of perjury, FACILITYORGANIZATION NUMBER, YOUR NAME print clearly, YOUR ADDRESS street city state zip, SOCIAL SECURITY NUMBER See Privacy, DRIVERS LICENSE NUMBERSTATE, DATE OF BIRTH, SIGNATURE, DATE, and Instructions to Licensees If the.

step 3 to finishing 508 criminal record form

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