Lic311A Form – Fill Out and Use This PDF

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
	COMMUNITY CARE LICENSING DIVISION

RECORDS TO BE MAINTAINED AT THE FACILITY - CHILD CARE CENTERS, INFANT CENTERS,

SCHOOL-AGE CENTERS AND CHILD CARE CENTERS FOR MILDLY ILL CHILDREN

THE FOLLOWING INFORMATION, which is required under sections of Title 22, California Code Of Regulations and/or Statute,

MUST BE KEPT IN THE FACILITY, COMPLETE AND CURRENT, AND READILY AVAILABLE FOR REVIEW.

I.Child's Records

A.Identification and Emergency Information - Child Care Centers (LIC 700).

B.Child's Preadmission Health History - Parents’ Report (LIC 702).

C.Child's Preadmission Health Evaluation if not enrolled in a public or private elementary school - Physician's Report (LIC 701).

D.Consent for Medical Treatment (LIC 627).

E.Written statement from parent(s) or authorized representative exempting child from medical assessment, immunizations,

and treatment because of adherence to a religious faith that practices healing by prayer or other spiritual means; or physician's statement that immunization is not indicated.

E1. California School Immunization Records (“blue cards”, PM 286) for non-school-age children.

F.Current Admission Agreement, with authorized signature(s).

G.Centrally Stored Medication and Destruction Record (LIC 622), if medications are handled.

H.Document of unusual behavior or signs of illness, special needs.

I.Unusual Incident/Injury Report (LIC 624).

J.Signed and dated receipt of Notification of Parents’ Rights (LIC 995).

K.Infant needs and services plan (for infant centers).

L.Toilet-training plan (for infant centers).

M.Infant-feeding plan (for infant centers).

N.Personal Rights — Community Care Facilities, Child Care Facilities (LIC 613A) receipts, signed and dated.

O.Authorizations for dispensing medication, signed by each child’s authorized representative.

P.Documentation required for health-related services (e.g., blood-glucose monitoring and nebulizer care).(LIC 9166)

Q.Gastrostomy Tube Care: Physician’s Checklist (LIC 701A).

R.Acknowledgement of receipt of licensing reports (LIC 9224), if applicable.

II.Personnel Records for Licensee, Director, Assistant Director, Teachers, Teacher's Aides, Support Staff, and Volunteers, if Appropriate. Documentation should be consistent with the LIC 500 and the LIS 555.

A.Health Screening Report - Facility Personnel (LIC 503) and TB Clearance.

B.TB Clearance and "Good Health" statement from volunteers.

C.Personnel Record (LIC 501) or application/resume.

D.Evaluation of Director Qualifications (LIC 9096).

E.Evaluation of Teacher Qualifications (LIC 9095).

F.For each aide under age 18, verification of high school graduation or current participation in an occupational program conducted by an accredited high school or college.

G.For each infant center aide, verification of graduation from high school or equivalent education or be enrolled in course

leading to graduation or have skills development potential; have experience in caring for children; verification of on-the-job training.

H.Criminal Record Statement (LIC 508) for staff subject to fingerprint requirements.

H1. Fingerprint clearances - Proof of clearance (Criminal Record, FBI and Child Abuse).

I.Appropriate driver's license for person(s) transporting children.

J.Documentation of actual hours worked (LIC 507).

K.Pediatric CPR/first aid cards for designated staff. At least one director or teacher must have the full 15 hours of health

and safety training. (However, at child care centers for mildly ill children, the director and each fully qualified teacher must have the full 15 hours of health and safety training.)

L.Valid water safety certificate for any adult given water-activity staffing responsibility.

M.Notice of Employee Rights (LIC 9052).

N.Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108).

O.Record of submission of Child Abuse Index Checks if not on LIS 555.

P.Appropriate transcripts (official.)

LIC 311A (3/07) Public

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III.Administrative Records

A..Written inspection procedures for accepting children on a daily basis.

B.Sign-in/sign-out sheets kept for current 30 days, or approved waiver to use electronic pin system.

C..Admission policies, including admission criteria, ages of children who will be accepted; medical assessment requirements; program activities, supplemental services, if any; field trip provisions, transportation arrangements, food service, if any.

D.Designation of Facility Responsibility (LIC 308).

E.Personnel Report (LIC 500) showing current roster.

F.Licensee affidavit regarding persons exempt from fingerprint requirements (Use back of LIC 500).

G.Emergency Disaster Plan (LIC 610) (a posting requirement; see below) with verification that disaster drills are conducted every six months. Documentation of drills shall be maintained for at least one year.

H.Up-to-date list of qualified teacher substitutes.

I.Documentation of exceptions and waivers: Facility Waiver Request (LIC 956) and Exception/Exemption Request (LIC 971).

J.Annual licensing reports and substantiated complaints from the last three years (must be available at the center for public review).

K.Child Care Facility Roster (LIC 9040).

IV. Documents to be posted at the Facility

A.Facility license.

B.Personal Rights form (LIC 613A).

C.Menus.

D.Child passenger restraint system poster. (PUB 269).

E.Daily activity schedule.

F.Emergency Disaster Plan (LIC 610) and Earthquake Preparedness Checklist (LIC 9148).

G.Parent’s Rights Poster (PUB 393).

H.Notice of Site Visit (LIC 9213).

I.Any licensing report documenting a type”A” citation must be posted for 30 days.

J.Any licensing report or other document verifying compliance or non-compliance with the Department’s order to correct a Type A deficiency must be posted for 30 days.

LIC 311A (3/07)

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CHILD CARE CENTERS - FORM NUMBER AND TITLE

Licensing Forms in English or Spanish may be accessed at http://www.ccld.ca.gov (*Available in Spanish)

*LIC 198A - Child Abuse Index Check

*LIC 308 - Designation of Facility Responsibility

*LIC 309 - Administrative Organization

*LIC 500 - Personnel Report

*LIC 501 - Personnel Record

*LIC 503 - Health Screen Report - Facility Personnel

LIC 507 - Facilities Staff Work Schedule

*LIC 508 - Criminal Record Statement

*LIC 610 - Emergency Disaster Plan

*LIC 613A - Personal Rights

*LIC 622 - Centrally Stored Medication and Destruction Record *LIC 624 - Unusual Incident/Injury Report

*LIC 627 - Consent For Emergency Medical Treatment

*LIC 700 - Identification & Emergency Information

*LIC 701 - Physicians Report

*LIC 702 - Child’s Preadmission Health History (Parent’s Report) LIC 956 - Facility Waiver Request

LIC 971 - Exception/Exemption Request

*LIC 995 - Child Care Center Notification of Parents’ Rights LIC 995E - Caregiver Background Check Process

*LIC 9040 - Child Care Faciity Roster

*LIC 9052 - Notice of Employee Rights

LIC 9095 - Evaluation of Teachers’ Qualifications

LIC 9096 - Evaluation of Director Qualifications

*LIC 9108 - Statement Reporting Suspected Child Abuse *LIC 9148 - Earthquake Preparedness Checklist

LIC 9163 - Request for Livescan Service

*LIC 9166 - Nebulizer Care Consent/Verification

LIC 9182 - Criminal Background Clearance Transfer Request LIC 9188 - Criminal Record Exemption Transfer Request *LIC 9194 - Livescan Instructions for State Licensed Facilities *LIC 9213 - Notice of Site Visit

*LIC 9224 - Acknowledgement of Receipt of Licensing Reports *PUB 269 - Child Care Seat Law Poster

*PUB 393 - Child Care Center Notification of Parents’ Rights Poster

LIC 311A (3/07)

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