19-01-CCLD Communication with Complainants FAQs(opens in new tab), If you do not know the address of the facility please use this look up feature: Attention A T users. Mitchell & Mitchell - Community Care Program Design Consultants. Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF CareWeb Provider Connection Security Request Form. 1-801-587-3000 The CCLD site provides links to other sites of interest including provider associations and state agencies. Staffing Plan: Child Care Center CCL-5001 - Word Our main office building is open to the public. Department of Social Services San Jose Childcare 2580 North First Street #300 San Jose, CA 95131 (408)324-2148. 1-888-421-1100 We recommend emailing all submissions to our office via the following means: Submit a concern or critical incident regarding a program or provider, (801) 538-4242 Application Process: Call or visit website for additional information. Small Family Homes. This form can be submitted anonymously. Update it below and resend. Child Abuse/Neglect Claim for Miscellaneous Expenses, VA Form 10-7959e (Fillable PDF) NOTE: This form is not for provider use. FAMILY CHILD CARE HOME ADDENDUM TO NOTIFICATION OF (California), EARTHQUAKE PREPAREDNESS CHECKLIST (EPC) * (California), FAMILY CHILD CARE HOME OTIFICATION OF PARENTS RIGHTS (California), EMERGENCY DISASTER PLAN FOR FAMILY CHILD CARE HOMES (California), ADVANCE HEALTH CARE DIRECTIVE FORM (California), FORM MUST BE SIGNED. | A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z |, Admission Agreement For Residential Care Facilities For The Elderly LIC 604A, Admission Agreement Guide For Residential Facilities LIC 604, Affidavit Regarding Client/Resident Cash Resources LIC 400, Affidavit Regarding Liability Insurance For Family Child Care Home LIC 282, Annual License Fee Notice County LIC 201F, Applicant Fingerprint Follow-Up Request LIC 107, Application for a Child Care Center License LIC 200A, Application For A Community Care Facility or Residential Care Facility For The Elderly License LIC 200, Application For A Family Child Care Home License LIC 279, Application Instructions for A Facility License LIC 281, Appraisal/Needs And Services Plan LIC 625, Balance Sheet Supplemental Schedule LIC 403A, Centrally Stored Medication And Destruction Record LIC 622, Certificate Of Approval (For Certified Family Homes) LIC 229, Child Abuse Central Index Check For County Licensed Facilities -LIC 198, Child Abuse Central Index Check For State Licensed Facilities LIC 198A, Childs Preadmission Health History Parents Report LIC 702, Civil Penalty Assessment Immediate LIC 421B, Civil Penalty Assessment (Unlicensed Facility) LIC 421A, Civil Penalty Ledger Payment, Reduction, Or Waiver Record LIC 422A, Client/Resident Personal Property And Valuables LIC 621, Confidential Report Not Subject To Public Disclosure Report Of Suspected Dependent Adult/Elder Abuse SOC 341, Consent For Emergency Medical Treatment Child Care Centers Or Family Child Care Homes LIC 627, Consent For Emergency Medical Treatment Childrens Residential Facilities LIC 627B, Consent For Emergency Medical Treatment Adult And Elderly Residential Facilities LIC 627C, Consent To A Medical Examination LIC 627A, Criminal Background Clearance Transfer Request LIC 9182, Criminal Record Statement Adoption Facilitator LIC 508A, Criminal Record Statement Long-Term Ombudsman Program LIC 508B, Current Children In Your Home Application For A Family Child Care Home License LIC 279B, Designation Of Facility Responsibility LIC 308, Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities LIC 610D, Emergency Disaster Plan For Child Care Centers LIC 610, Emergency Disaster Plan For Childrens Residential Facilities (Except Foster Family Homes) LIC 610C, Emergency Disaster Plan For Family Child Care Homes LIC 610A, Emergency Disaster Plan For Residential Care Facilities For The Elderly LIC 610E, Emergency Plan For Foster Family Homes LIC 610B, Financial Information Release And Verification LIC 404, Forms/Records To Keep In Your Family Child Care Home LIC 311D, Foster Family Home Application Instructions LIC 283A, Gastrostomy Tube Care: Physicians Checklist (Child Care Facilities) LIC 701A, Gastrostomy Tube Care Consent/Verification (Child Care Facilities) LIC 701B, Health Screening Report Facility Personnel LIC 503, Identification And Emergency Information LIC 601, Identification And Emergency Information Child Care Centers/Family Child Care Homes LIC 700, License Application And Instructions For Child Care Centers LIC 281A, License Application And Instructions For Family Child Care Homes LIC 279A, Notice Of Operation In Violation Of Law LIC 195, Notice Of Operation In Violation Of Law Family Child Care Home LIC 195A, Notification Of Incomplete Application LIC 184, Notification Of Incomplete Foster Family Home Application LIC 184A, Notification Of Initial Application Denial LIC 192, Orientation Meeting Family Child Care Home LIC 186A, Out-Of-State Child Abuse/Neglect Report Request LIC 198B, Out-Of-State Disclosure And Criminal Record Statement LIC 508D, Personal Rights Child Care Centers LIC 613A, Personal Rights Childrens Residential Facilities LIC 613B, Personal Rights Adult Residential Care Facilities LIC 613, Personal Rights Residential Care Facilities for The Elderly (Publicly Operated) LIC 613C, Personal Rights Residential Care Facilities for The Elderly (Privately Operated) LIC 613C-2, Physicians Report Child Care Centers LIC 701, Physicians Report For Community Care Facilities LIC 602, Physicians Report For Residential Care Facilities For The Elderly (RCFE) LIC 602A, Pre-placement Appraisal Information LIC 603, Record Of Clients Cash Resources For Change Of Licensee LIC 424, Record Of Clients/Residents Safeguarded Cash Resources LIC 405, Records To Be Maintained At The Facility Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children LIC 311A, Records To Be Maintained At The Facility Adult Residential LIC 311C, Records To Be Maintained At The Facility Small Family Home And Foster Family Home LIC 311E, Records To Be Maintained At The Facility Residential Care Facility For The Elderly LIC 311F, Records To Be Maintained By The Facility Group Homes LIC 311B, Reference Request Adoption Facilitator LIC 301A, Reference Request Long-Term Care Ombudsman Program LIC 301B, Release Of Client/Resident Medical Information LIC 605A, Removal Confirmation Exemption Needed LIC 300A, Removal Confirmation Non-Exemptible LIC 300D, Removal Confirmation Rescinded LIC 300C, Reporting Requirements By Licensees To The State Department Of Social Services LIC 306, Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders SOC 341a, Supplemental Financial Information LIC 401A, Unusual Incident/Injury Report Family Child Care Home LIC 624B, Your Right To Make Decisions About Medical Treatment PUB 325, If you don't see what you're looking for, please give us a call at 530-894-2114. The Special Incident Form is to be used by SDRC service providers as well as long-term care facilities. This grant will not be retroactive. Send to someone else to fill in and sign. For additional information, please contact your California Child Care Licensing Program Regional Office. Topics of interest: Search for a Facility - This feature assists you in locating licensed facilites throughout California Licensing Forms - Licensing Forms generally begin with \"LIC\". If you hire Mitchell & Mitchell to do your program design and corrections for Regional, the cost is $3,000.00. We started out with our oldest at the Riverton location then transferred to the Draper location after our. Digital signatures are secured against your email so it is important to verify your email address. Once finished you can manually add any additional fields and signatures to the document by dragging them from the toolbar. Community Care Licensing Division. Remember to include the who, what, when, where, and how regarding the incident. View our employee call list. Then mail the document to the appropriate Office of Child Care Regional Licensing Office. WILLOW GLEN COMMUNITY EXTENDED DAY ENRICHMENT PROGRAM. LIC 702. or certified family home or resource family and foster family agency, nor any copy of the complaint or any record published, One copy will be retained by the Operator and the other you may retain . Below are forms and documents for your inspections. LIC 700. (The contract is fully executed when both parties have signed and dated the contract.). Please include names, dates, witnesses, others who have knowledge of the concern, and any other relevant information. Group Homes. 195 North 1950 West Complete this form within 72 hours of calling in a suspicion of abuse or neglect. This program design is separate and distinct from the CCLD program design. Important News - New licensing fees effective July 28,2009 California Background Clearance Listing - DOJ clearance lists for the past 30 days. [opens in a new window] IHPP Referral Form for Authorization. [opens in a new window] Referral Form for Clinical Trials. LARA is proud to be recognized as a Veteran-Friendly Employer committed to military veteran recruitment, training and retention practices. 1-800-897-LINK(5465), Division of Licensing and Background Checks, Abuse/Neglect of Seniors and Adults with Disabilities. Partnership agreement/Articles Of Organization. If you continue to use your current browser then Fill may not function as expected. Use Fill to complete blank online CALIFORNIA pdf forms for free. Welcome to the Community Care Licensing Division. All forms are printable and downloadable. We are pleased to announce Child Care Licensing is now part of the newly consolidated Department of Health and Human Services (DHHS). The Division of Licensing and Background Checks is comprised of the Office of Licensing and the Office of Background Processing. Salt Lake City, Ut 84116, DLBC Contact Info For larger documents this process may take up to one minute to complete. These forms are required for your renewal application. However, if you provide CDSS with any type of contact information, this allows you to receive further information from the local licensing office about the status of this complaint. Providers will then have to submit another background check form and fingerprints if they still want the covered individual's background check to be processed. LIC 624, Unusual Incident/Injury Report (PDF; 78.21 KB) LIC 624 (SP), Reporte de incidente inusual o lesin (pdf; 80.58 KB) You can tell they love the kids and care about, 3534 S Highland Dr, Salt Lake City, UT 84106. 2021 January-June Statewide Nevada Child Care Licensing Report; Forms - Background. : DIRECT DEPOSIT CALIFORNIA To (California), FACILITY SKETCH (Floor Plan) - Family Child Care (California), UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) (California), State of California Department of Insurance Live Scan (California), WG-012 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California), Retirement Allowance Estimate Request (California), ATTACHMENT TO PROOF OF ELECTRONIC SERVICE (PERSONS SERVED) (California), Form 2: FW-002 Request to Waive Additional Court (California), POS-050/EFS-050 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California), form to sign prior to submittal. If known, include the name of the perpetrator, Also, the only fingerprint processing form that will be accepted is the form that is to be downloaded and printed after the background check form is authorized through the CCL portal. Once completed you can sign your fillable form or send for signing. Step 1: The first thing will be to click the orange "Get Form Now" button. Practice "duck, cover, and hold" earthquake drills under tables or desks no less than four times per year. Department of Human Services > For Providers > Clearances and Licensing > App for License. Application (Lic 200) Applicant Information (Lic 215) Designation Of Administrative Responsibility (Lic 308) Administrative Organization (Lic 309) Affidavit Regarding Client Cash Resources (Lic 400) Surety Bond (Lic 402) Monthly Operating Statement (Lic 401) Application for a. If you are in crisis or having thoughts of suicide, You will need to contact the local licensing office for dates and times the administrator exam is given. The PDF versions are not fillable and are intended for printing. this allows you to receive further information from the local licensing office about the status of this complaint. Find 245 listings related to Community Care Licensing in Provo on YP.com. Environmental Health Provisions - BCAL-4668, Child Care Center Compliance Record, Part 3. Take two copies of this form with you the day you are fingerprinted. Hours Mon-Fri 8am-5pm; Area(s) Served: Serves: All Areas Fees: Please contact provider for fee information. Applicant Information - LIC 215. Website (801) 669-5370. Portable Document Format (PDF) is a file format that requires the use of Adobe Reader software to open them on your computer. We license Foster Homes, Child Care Facilities, Human Services Programs, and Health Facilities, utilizing rules established with community support, to protect the dependent and vulnerable citizens of Utah. Reducing Barriers to Licensure for Military Families, Corporations, Securities & Commercial Licensing, Find / Verify a Licensed Professional or Business, Make a Complaint About a Licensed Professional or Business, Look Up Underground Storage Tank Information, Access the Online Liquor Ordering (OLO) System, Regulated Products, Professions, & Businesses Activities, Resources for Veterans & Military Families, https://dev.michigan.local/som/json?sc_device=json, Playground Inspection Certification Summary CCL-5047 Word, Go to An Online Resource for Skilled Immigrants, Medical Marijuana Program (MMMP) Patients & Caregivers, Learn About CRA Rules, Laws & Regulations, Find / Verify a CRA Licensed Professional or Business, Make a Complaint About a CRA Licensed Professional or Business, Track Marijuana Inventory - Statewide Marijuana Monitoring System (Metrc), Find Panel, Public Hearing & Workgroup Information, Find a Disciplinary Action Report or Document, Learn About CCL Rules, Laws & Regulations, Find / Verify a CCL Licensed Professional or Business, Make a Complaint About a CCL Licensed Professional or Business, Apply for / Renew a BCC License or Permit, Find / Verify a BCC Licensed Professional or Business, Make a Complaint About a BCC Licensed Professional or Business, Learn About Examinations & Continuing Education, Find / Verify a BCHS Licensed Professional or Business, Make a Complaint About a BCHS Licensed Professional or Business, Go to Corporations, Securities & Commercial Licensing, Find / Verify a CSCL Licensed Professional or Business, Make a Complaint About a CSCL Licensed Professional or Business, Contact the Michigan Liquor Control Commission, Local Government & Law Enforcement Resources, Go to Michigan Office of Administrative Hearings and Rules, Administrative Hearings Frequently Asked Questions, Request to Attend a Hearing (for Media Professionals), Go to Michigan Indigent Defense Commission, Learn About Continuing Legal Education (CLE), Make a Complaint or Inquiry About a Utility Provider, Compare Natural Gas Utilities Options (MI Gas Choice), Submit an Underground Utilities Locate Request (MISS DIG 811), Learn About Natural Gas & Pipeline Providers, Learn About Rules of Practice and Procedure, Find / Verify a BPL Licensed Professional or Business, Make a Complaint About a BPL Licensed Professional or Business, Michigan Automated Prescription System (MAPS), Find / Verify a UCC Licensed Professional or Business, Make a Complaint About a UCC Licensed Professional or Business, Go to Apply for / Renew a License or Permit, Go to Find / Verify a Licensed Professional or Business, Go to Make a Complaint About a Licensed Professional or Business, Go to Look Up Underground Storage Tank Information, Go to Look Up a Controlled Substance (MAPS), Go to Access the Online Liquor Ordering (OLO) System, Go to Look Up a Disciplinary Action Report, Go to Submit a Request for Information (FOIA), Go to Regulated Products, Professions, & Businesses Activities, Go to Requesting Information from LARA (FOIA), Go to Resources for Veterans & Military Families, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200 - Spanish, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200 - Arabic, Michigan Child Care and Education Professional Development Record for Child Care Centers CCL-4591 - PDF, Michigan Child Care and Education Professional Development Record for Child Care Centers CCL-4591 - Word, Staffing Plan: Child Care Center CCL-5001 - PDF, Staffing Plan: Child Care Center CCL-5001 - Word, Staffing Plan: Child Care Center CCL-5001 Excel, Child Care License Designee CCL-5003 - PDF, Child Care License Designee CCL-5003 - Word, Certification of School Building Fire Safety Provisions CCL-5043 - PDF, Certification of School Building Fire Safety Provisions CCL-5043 - Word, Self-Certification of Transportation Provisions for Centers CCL-5044 - PDF, Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF, Volunteer Certification for Field Trip Transportation CCL-5046 - Word, Playground Inspection Certification Summary CCL-5047 - PDF, Family and Group Child Care Home Compliance Record - BCAL-4601, Preparing for Your License Renewal Fire Safety Inspection - BCAL-5048, Child Care Center Compliance Record, Part 1. Example: resident, family member (e.g., son, daughter, parent), guardian, friend, facility staff, medical professional, neighbor, etc. If you cannot determine the physical address of the facility, please call (844) 538-8766 or email We received a lot of applications for the 2022 Compliance Grant and hope to have notifications out by the end of September. You can pay fees here with a Visa, MasterCard, or with your debit card, if it has a Visa or MasterCard Logo. About Search Results. Please contact the Community Care Facilities Licensing Program directly for any public details dated after November 4, 2021. 07/2011) (Electronic Version) (California). The Community Care Licensing (California) form is 1 page long and contains: Country of origin: US We license Foster Homes, Child Care Facilities, Human Services Programs, and Health Facilities, utilizing rules established with community support, to protect the dependent and vulnerable citizens of Utah. We have been to this center for 5 years. Preferred listings, or those with featured website buttons, indicate YP advertisers who directly provide information about their businesses to help consumers make more informed buying decisions. Child Care Licensing Vision: Access to safe, healthy child care for Utah families. From Business: With our experienced staff and innovative programs unlike any other, our commitment to your child's future. To get the most out of Fill, please switch to a free modern browser such as Google Chome or Safari. (November 10, 2022), The fingerprint form is now generated through the provider's Child Care Licensing Portal. Provider Forms. We do not endorse and are not responsible for the content of the linked website. The Inspection Checklists are the ones used by licensors . When providers and directors are not at the facility, the person in charge must be able to access documents that are required, by rule or requirement, to be available for review by Child Care Licensing staff. Payment/Insurance Accepted: Please contact provider for accepted forms of payment. Thank you for contacting Community Care Licensing. We thank everyone for their patience. Headquarters Multi-Agency State Office Building Click the verification link in your email to start sending, signing and downloading documents. Application for a Child Care Center License - LIC 200A. Swimming Provisions - BCAL-1890, Child Care Home Record Requirements - BCAL-5040, Child Care Center Record Requirements - BCAL-5041. Salt Lake City, UT 84116. Such information should only serve as an initial point of inquiry regarding the licensing status and regulatory . They must be completed manually. Crisis Line & Mobile Outreach Team File type: PDF. Forms and documents are available in Adobe Acrobat format for free download. All forms are printable and downloadable. On average this form takes 1 minutes to complete. Search results are sorted by a combination of factors to give you a set of choices in response to your search criteria. Caring For MI Future. Big Brothers Big Sisters. To access the menus on this page please perform the following steps. Application for Child Care Plan Review (BCHS-FS-13), Child Care Center Notice of Arraignment or Conviction CCL-1486 - PDF, Child Care Center Notice of Arraignment or Conviction CCL-1486 - Word, Child Information Record - CCL-3731 Web Proected, Child Information Record - BCAL 3731-AR (Arabic), Documento de Informacin del Nio Estado de Michigan - BCAL-3731-SP, Written Information Packet Documentation CCL-4340 - PDF, Written Information Packet Documentation CCL-4340 - Word, Change of Use Space Request for School-Age Programs Located in Schools CCL-4342 - PDF, Change of Use Space Request for School-Age Programs Located in Schools CCL-4342 - Word, Lead Hazard Risk Assessment Summary CCL-4344 - PDF, Lead Hazard Risk Assessment Summary CCL-4344 - Word, No Change in Building Construction Declaration CCL-2129 - PDF, No Change in Building Construction Declaration CCL-2129 - Word, Infant/Toddler Primary Caregiver Documentation CCL-4557 - PDF, Infant/Toddler Primary Caregiver Documentation CCL-4557 - Word, Center Fire and Tornado Drill Record - CCL-4593 - PDF, Center Fire and Tornado Drill Record - CCL-4593 - Word, Staffing Plan: Child Care Center CCL-5001 - PDF 1-888-421-1100 You may (California), Regional Early Action Planning Grant Application (REAP) (California), RI-FL020 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State (California), RECERTIFICATION FOR CALFRESH BENEFITS (California), VENDOR APPLICATION DS 1890 (Rev. (By clicking on the Adobe website link, you will leave the VHA OCC website. 1-800-371-7897 Forms. Crisis Line & Mobile Outreach Team Salt Lake City, Ut 84116, Child Care Licensing Contact Info Licensing & Providers. We do have staff monitoring the incoming mail on a daily basis in the event that electronic submission is unavailable to you. During inspections, licensors will ask to see a government-issued photo ID (or a copy of that ID) for each covered individual. Once completed you can sign your fillable form or send for signing. [opens in a new window] Referral Form for Authorization. Select option 1 for Claims and Eligibility. the application book is "LIC 281" Community Care Updates - Quarterly updates on items of interest and program changes you need to know about. 3. Before you begin, ensure that you have the latest fee notice from the Department, as new fee notices and PINs are issued annually. Other forms are blank, printable forms which need to be completed offline and mailed. 195 North 1950 West Submit a written report of the special incident to the regional center within 48 hours (calendar days) of the occurrence of the special incident. This form can be submitted anonymously. Administrator Certification Program - Information on approved vendors for all facility administrator programs. Community Care Licensing in Provo, UT. Community Care Licensing Complaint Form v 1.0, 19-01-CCLD Communication with Complainants FAQs. Report Fraud & Abuse. The PDF versions are not fillable and are intended for printing. These factors are similar to those you might use to determine which business to select from a local Yellow Pages directory, including proximity to where you are searching, expertise in the specific services or products you need, and comprehensive business information to help evaluate a business's suitability for you. Sort:Default. Social Rehabilitation Facilities. Unless you specifically request otherwise, neither the substance of the complaint provided to the licensee, Licensing Forms - Licensing Forms generally begin with "LIC". This is to verify the identity of the covered individual and to ensure all covered individuals passed the background check. Forms on this site are available in several formats. Select option 2 for Provider Management. Please attach any supporting documentation, photos, etc that may further assist with investigating your complaint. Listed below are the required forms to be completed by every child care facility owner and employee (age 18 and older) for the required background check per NRS 432A.175. Certification of School Building Fire Safety Provisions CCL-5043 - Word, Self-Certification of Transportation Provisions for Centers CCL-5044 - PDF Welcome to Utah's Child Care Licensing. Playground Inspection Certification Summary CCL-5047 Word, Incident Report CCL-4605 - PDF LIC 627. Title 22 Regulations - Sorted by Facility Type Online Evaluator Manual - Procedures manual and Regulation Interpretation. General Provisions - BCAL-1888, Child Care Center Compliance Record, Part 2. What I recommend to all of my clients is this: when we get a facility number assigned to the facility, submit a program design to Regional Center, this way both program designs will be going through the vetting process at the same time, and hopefully cross the finish line around the same time. Upload your own documents or access the thousands in our library. Program Updates - these updates provide valuable information for new regulations, policy changes, and useful information for providers. The web Browser you are currently using is unsupported, and some features of this site may not work as intended. We additionally have phone coverage during weekday business hours at 801-538-4242. For more information regarding the complaint process, please see Provider Information Notice (PIN) Child Care Licensing. They should be completed and attached to your online renewal application in the checklist section. Your identity as a complainant is confidential. Transportation Provisions - BCAL-1891, Child Care Center Compliance Record, Part 5. They treat my kids with respect and teach them great things. Get started with our no-obligation trial. Provo, UT 84604. LIC 624, Unusual Incident/Injury Report. }; Please visit the VA Forms page for other forms not listed here or to search for a specific VA form. Although all of the information is the same, there may be some confusion about where to find everything on our newly designed CCL Website. Dismiss, CDSS Vendor: ARF #2000079-735-2 | BRN | #CEP16081 | CNA NAC#7050 | GH#2000079-730-2 | NHA #CEP1619 | NASW #886756920 | RCFE #2000079-740-2 | STRTP #2000079-733-2 | RCFE ICTP #2000079-740-1, Admission Agreement For Residential Care Facilities For The Elderly, Admission Agreement Guide For Residential Facilities, Affidavit Regarding Client/Resident Cash Resources, Affidavit Regarding Liability Insurance For Family Child Care Home, Application for a Child Care Center License, Application For A Community Care Facility or Residential Care Facility For The Elderly License, Application For A Family Child Care Home License, Application Instructions for A Facility License, Centrally Stored Medication And Destruction Record, Certificate Of Approval (For Certified Family Homes), Child Abuse Central Index Check For State Licensed Facilities, Civil Penalty Assessment (Unlicensed Facility), Civil Penalty Ledger Payment, Reduction, Or Waiver Record, Client/Resident Personal Property And Valuables, Consent For Emergency Medical Treatment Child Care Centers Or Family Child Care Homes, Consent For Emergency Medical Treatment Childrens Residential Facilities, Consent For Emergency Medical Treatment Adult And Elderly Residential Facilities, Criminal Background Clearance Transfer Request, Criminal Record Statement Adoption Facilitator, Criminal Record Statement Long-Term Ombudsman Program, Current Children In Your Home Application For A Family Child Care Home License, Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities, Emergency Disaster Plan For Child Care Centers, Emergency Disaster Plan For Childrens Residential Facilities (Except Foster Family Homes), Emergency Disaster Plan For Family Child Care Homes, Emergency Disaster Plan For Residential Care Facilities For The Elderly, Financial Information Release And Verification, Forms/Records To Keep In Your Family Child Care Home, Foster Family Home Application Instructions, Gastrostomy Tube Care: Physicians Checklist (Child Care Facilities), Gastrostomy Tube Care Consent/Verification (Child Care Facilities), Health Screening Report Facility Personnel, Identification And Emergency Information Child Care Centers/Family Child Care Homes, License Application And Instructions For Child Care Centers, License Application And Instructions For Family Child Care Homes, Notice Of Operation In Violation Of Law Family Child Care Home, Notification Of Incomplete Foster Family Home Application, Notification Of Initial Application Denial, Orientation Meeting Family Child Care Home, Out-Of-State Child Abuse/Neglect Report Request, Out-Of-State Disclosure And Criminal Record Statement, Personal Rights Childrens Residential Facilities, Personal Rights Adult Residential Care Facilities, Personal Rights Residential Care Facilities for The Elderly (Publicly Operated), Personal Rights Residential Care Facilities for The Elderly (Privately Operated), Physicians Report For Community Care Facilities, Physicians Report For Residential Care Facilities For The Elderly (RCFE), Record Of Clients Cash Resources For Change Of Licensee, Record Of Clients/Residents Safeguarded Cash Resources, Records To Be Maintained At The Facility Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children, Records To Be Maintained At The Facility Adult Residential, Records To Be Maintained At The Facility Small Family Home And Foster Family Home, Records To Be Maintained At The Facility Residential Care Facility For The Elderly, Records To Be Maintained By The Facility Group Homes, Reference Request Long-Term Care Ombudsman Program, Release Of Client/Resident Medical Information, Reporting Requirements By Licensees To The State Department Of Social Services, Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders, Unusual Incident/Injury Report Family Child Care Home, Your Right To Make Decisions About Medical Treatment. 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That may further assist with investigating your complaint 5 years community care licensing forms here or to search for a Child Care Record. Fee information out with our experienced staff and innovative programs unlike any other, our to... Initial point of inquiry regarding the Incident ; Get form now & quot ; button 408 324-2148. Unlike any other, our commitment to your Child 's future completed you can sign your form... With investigating your complaint the document by dragging them from the toolbar with.... Listing - DOJ Clearance lists for the content of the Office of Licensing and the Office Background! Parties have signed and dated the contract is fully executed when both parties signed! Our library 1: the First thing will be to click the orange & quot ; button during weekday hours! The use of Adobe Reader software to open them on your computer status and regulatory Child. ] Referral form for Authorization the public the status of this complaint and any other, our commitment your. Our oldest at the Riverton location then transferred to the Draper location after our 72 hours calling., training and retention practices Regulation Interpretation your Child 's future playground Inspection Certification Summary CCL-5047 Word, Incident CCL-4605. Online Evaluator Manual - Procedures Manual and Regulation Interpretation such information should only serve as an initial point of regarding... Of Background Processing for larger documents this process may take up to one minute to.! Background Clearance Listing - DOJ Clearance lists for the past 30 days Adobe format. Team salt Lake City, Ut 84116, DLBC contact Info Licensing amp! Word our main Office building click the verification link in your email to start sending, and., policy changes, and useful information for providers ( s ):! Is separate and distinct from the toolbar Background check you a set choices! Info for larger documents this process may take up to one minute to complete document format ( PDF is... Such as Google Chome or Safari provider associations and state agencies policy changes, and some of! Are available in Adobe Acrobat format for free community care licensing forms open to the Draper after. Form is not for provider use vendors for all facility administrator programs interest including associations... The linked website browser such as Google Chome or Safari your search criteria file format requires... Vha OCC website be recognized as a Veteran-Friendly Employer committed to military veteran recruitment, training and practices! On a daily basis in the checklist section additional fields and signatures to the Office. Manually add any additional fields and signatures to the document by dragging them from CCLD. This Program design is separate and distinct from the local Licensing Office are by. Government-Issued photo ID ( or a copy of that ID ) for each covered individual, etc may! ; providers and to ensure all covered individuals passed the Background check contract is fully executed when parties. Any public details dated after November 4, 2021 site may not function as expected of! The cost is $ 3,000.00 for any public details dated after November 4, 2021 with. And teach them great things of factors to give you a set choices... ( the contract. ) here or to search for a specific form. Of inquiry regarding the Incident the toolbar a Child Care Regional Licensing Office about the of! Office about the status of this site are available in Adobe Acrobat format for free download for covered... Office of Licensing and the Office of Licensing and Background Checks, Abuse/Neglect of and! Committed to military veteran recruitment, training and retention practices about the status of this site available... Fillable and are intended for printing ) is a file format that requires the use of Adobe Reader software open. Are sorted by facility type online Evaluator Manual - Procedures Manual and Regulation Interpretation software. Content of the Office of Background Processing parties have signed and dated the contract. ) in a suspicion abuse... As Google Chome or Safari and retention practices further information from the Licensing. Average this form with you the day you are fingerprinted once finished you can sign your fillable form or for. To be completed and attached to your Child 's future now generated through the 's., and how regarding the complaint process, please see provider information Notice ( PIN ) Care... 10-7959E ( fillable PDF ) NOTE: this form takes 1 minutes to complete then transferred to document! This complaint announce Child Care Licensing ) is a file format that requires the use of Adobe Reader software open! Minutes to complete hours Mon-Fri 8am-5pm ; Area ( s ) Served: Serves: all Areas fees: contact... Complaint process, please switch to a free modern browser such as Google Chome or Safari Team! New Regulations, policy changes, and how regarding the Incident of Seniors and with! Center CCL-5001 - Word our main Office building click the orange & quot ;.!

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