The LIC 500 form is a crucial document used by the California Department of Social Services to maintain an up-to-date roster of personnel at various facilities. This form captures essential information about staff members, including their job titles and hours of duty, while ensuring compliance with criminal background check requirements. By accurately reporting changes in personnel, facilities can uphold safety standards and regulatory obligations.
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STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERSONNEL REPORT
INSTRUCTIONS: This form is intended for keeping a current roster of all the facility personnel, other adults and licensees residing in the facility, including backup persons, volunteers and licensee if administrator/director. Show license/certificate number if applicable for specialized staff [e.g., Social Worker and other consultant(s)]. Show coverage for twenty-four hour supervision in residential facilities. Report any changes in personnel to the licensing agency as required by regulations. Send original to Licensing Agency and retain copy in facility file.
NAME OF FACILITY
FACILITY TYPE
FACILITY NUMBER
PREPARED BY
DATE
A.STAFF SUBJECT TO CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following staff members are subject to a criminal background check pursuant to Sections 1522, 1568.09, 1569.17 and 1596.871 of the Health and Safety Code. A California background clearance or a criminal record exemption shall be obtained prior to employment, residence or initial presence in the facility.
SPECIFY
NAME
JOB TITLE
DAYS AND HOURS ON DUTY
EMPL'D
DAYS
FROM
TO
Licensee/Administrator
LIC 500 (11/03) (PUBLIC)
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B.STAFF EXEMPT FROM CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following are believed exempt from criminal background check requirements pursuant to Sections 1522, 1568.09, 1569.17 and 1596.871 of the Health and Safety Code. The licensee or designated representative shall sign below to verify that he or she believes the indicated persons are exempt from criminal background check requirements pursuant to statute.
Signature ________________________________________________________________________________ Date __________________
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When managing a facility, especially in the health and human services sector, it's essential to keep a variety of documents organized and up to date. The Lic 500 form plays a crucial role in maintaining a current roster of personnel, but several other forms complement it. Here’s a brief overview of some key documents that are often used alongside the Lic 500 form.
By maintaining these documents alongside the Lic 500 form, facilities can ensure compliance with regulations, promote safety, and provide quality care. Each form plays a unique role in the overall management of personnel and resident welfare, contributing to a well-organized and efficient operation.