Form Lic 9182 PDF Details

Navigating the procedural aspects of transferring active criminal record clearances between state-licensed facilities or organizations is efficiently handled through the LIC 9182 form, which serves as an essential document in the State of California, under the oversight of the Health and Human Services Agency and the California Department of Social Services’ Community Care Licensing Division. This form is a critical tool for license applicants or licensees who wish to transfer criminal background clearances of individuals, ensuring the smooth continuation of their employment or association with a different licensed entity without compromising on client safety or legal compliance. It mandates the submission of specific identification documents and, where applicable, a Child Abuse Central Index (CACI) check to validate the transfer request. Additionally, this process highlights a commitment to privacy and adherence to federal and state regulations concerning personal information while making clear the repercussions of unapproved or delayed transfers, particularly the risks of violating laws and the imposition of civil penalties. With detailed instructions on its usage, the LIC 9182 form underscores a procedural necessity for facilitating workforce mobility within California’s network of health and human services while upholding stringent safety and regulatory standards.

QuestionAnswer
Form NameForm Lic 9182
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesillinois state police blank dom of information release form, lic9182, criminal background transfer request, seq

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING DIVISION

CRIMINAL BACKGROUND CLEARANCE TRANSFER REQUEST

Active criminal record clearances may be transferred from one state licensed facility/organization to another by a license applicant or licensee. The transfer request must be submitted to the Department before the individual who is the subject of the transfer has client contact or the facility/organization will be in violation of the law and subject to a $100 civil penalty.

The license applicant or licensee who is seeking the transfer must provide a LIC 508, and verify the individual’s identity and include a copy of the person’s driver’s license, permanent resident card or a valid photo identification issued by the California Department of Motor Vehicles or by another state or the United States government if the person is not a California resident. Additionally, a Child Abuse Central Index (CACI) check must be submitted if the transfer is to a facility serving children and the individual has not previously submitted a CACI check or the date of the previous CACI inquiry was made prior to January 1, 1999. The CACI must be mailed directly to the Department of Justice with the applicable fee. Note: This transfer request is for clearances only. Contact your licensing office for information about exemption transfers.

This form may only be used to request a clearance transfer between state licensed facilities/organizations. To request a transfer between county and state licensed facilities, the requesting Licensing Agency must contact their county liaison.

PLEASE TYPE OR PRINT LEGIBLY

DATE:

PLEASE TRANSFER THE CRIMINAL RECORD CLEARANCE FOR THE FOLLOWING INDIVIDUAL:

LAST NAME

FIRST NAME

MIDDLE INITIAL

CA DRIVER’S LICENSE OR ID #/PERMANENT RESIDENT ID# (i-551):

DOB:

LICENSING INFORMATION SYSTEM ID#:

SSN: (OPTIONAL)

FROM THE FOLLOWING FACILITY/ORGANIZATIONS:

NAME OF FACILITY/ORGANIZATION:

FACILITY/ORGANIZATION NUMBER:

STREET ADDRESS:

CITY

STATE

ZIP CODE:

TO THE FOLLOWING FACILITY/ORGANIZATION: ■ PLEASE ALSO KEEP THIS INDIVIDUAL ASSOCIATED WITH ABOVE FACILITY/ORGANIZATION.

 

NAME OF FACILITY/ORGANIZATION:

 

 

Transferee Association Type

 

 

 

 

 

■ Facility Administrator

 

 

 

 

 

■ Corporation Board Member

 

 

FACILITY/ORGANIZATION NUMBER:

 

DATE OF EMPLOYMENT:

 

 

 

 

 

 

 

 

 

■ Employee

 

 

 

 

 

■ Certified Home

 

 

 

 

 

■ Licensee/Applicant

 

STREET ADDRESS:

 

 

 

 

 

 

 

■ Non-client Adult Resident

 

 

 

 

 

■ Partnership Member

 

CITY

STATE

ZIP CODE:

 

■ Spouse of Licensee

 

 

 

 

 

 

 

 

 

 

■ Affiliated Home Care Aide

 

 

 

 

 

 

 

I certify I have verified the above individual’s identity and have enclosed a copy

Title (licensee, administrator, director)

 

 

of the individual’s photo I.D and LIC 508.

 

 

 

 

Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR DISTRICT OFFICE USE ONLY

 

 

DATE OF TRANSFER ENTRY:

INITIAL OF PERSON ENTERING TRANSFER:

LIC 9182 (11/15)

FILE IN NEWLY ASSOCIATED FACILITY/ORGANIZATION FILE

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING DIVISION

PRIVACYSTATEMENT

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

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 9182 (11/15)

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Ways to fill out CACI step 1

2. Immediately after the last array of fields is done, proceed to type in the applicable information in all these - FACILITYORGANIZATION NUMBER, DATE OF EMPLOYMENT, STREET ADDRESS, CITY, STATE, ZIP CODE, Facility Administrator, I certify I have verified the, Title licensee administrator, Signature, DATE OF TRANSFER ENTRY, INITIAL OF PERSON ENTERING TRANSFER, FOR DISTRICT OFFICE USE ONLY, LIC, and FILE IN NEWLY ASSOCIATED.

CITY, LIC, and Signature in CACI

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