Lic 9040 Form PDF Details

Navigating the requirements for maintaining child care facility records is crucial for ensuring compliance with state regulations. The LIC 9040 form, provided by the State of California Health and Human Services Agency and issued by the California Department of Social Services, is designed specifically for child care centers, including infant care centers, school-age centers, and family child care homes, to keep a detailed roster of children in their care. This documentation, which must be retained for three years, plays a pivotal role in upholding the standards for child safety and welfare as mandated by the Health and Safety Code Section 1596.841. The code stipulates that each child care facility keeps an up-to-date roster that includes vital information such as the child's name, address, parents' or guardians' names along with their day phone numbers, and the contact information of the child's physician. While the use of the LIC 9040 form is optional, it serves as a valuable tool for facilities aiming to meet these requirements effectively. This form not only aids in organizing important data but also ensures that the information is readily available for review by the licensing agency upon request, underscoring the facility's commitment to transparency and regulatory compliance.

QuestionAnswer
Form NameLic 9040 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameslic 9040 spanish, lic 9040 forms california, fill lisc9040, lic 9040 form

Form Preview Example

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CHILD CARE FACILITY ROSTER (RETAIN FOR 3 YEARS)

CHILD CARE CENTERS, INFANT CARE CENTERS, SCHOOL AGE CENTERS AND FAMILY CHILD CARE HOMES

NOTE: This roster must be kept in a central location at the facility, updated as needed and made available to the licensing agency upon request.

Health and Safety Code Section 1596.841 requires that each child care facility maintain a current roster of children who are provided care in the facility. The roster shall include the child’s name, address, names and day phone numbers of the parent(s) or guardian(s) and name and phone number of the child’s physician. This is an optional form that may be used for this purpose.

FACILITY NAME:

FACILITY LICENSE NUMBER:

DATE/UPDATE:

CHILD’S NAME/

BIRTHDATE

ADDRESS

PARENT/GUARDIAN

NAME(S)

DAYTIME PHONE OF PARENT/GUARDIAN

PHYSICIAN NAME

AND PHONE

DATE

ENROLLED

DATE LEFT

LIC 9040 (10/05)

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