Monitoreo de patrocinadores (CDSS-609) Estado actual. The California Department of Social Services (CDSS) serves, aids and protects needy and vulnerable children and adults in ways that strengthen and preserve families, encourage personal . Report changes as required. Note: The signed CBA and the completed Contract Data Summary Sheet (CDSS . New: CDSS has launched a Mobile App for this website now available on the App Store and Google Play. Complaint forms are available here: DHCS-1044-DHCS-DISCRIMINATION-COMPLAINT-FORM.pdf. 5. MC 300 Forms: MC 306 (11/15) - Appointment of Representative; Alt: Spanish (01/08) MC 322 (05/07) - Real and Personal Property - Supplement to Medi-Cal Mail-in Application Application for Services. Traduzioni in contesto per "CDSS a" in italiano-inglese da Reverso Context: In passato, gli studenti dovevano frequentare la scuola Ezondweni CDSS a 6 km di distanza. *To order forms in braille, please contact program directly. SOC 2298 - In-Home Supportive Services (IHSS) Program and Waiver Personal Care Personal Services (WPCS) Live-In Self-Certification Form for Federal and State Wage Exclusion. Resources for Parents and Families Resources for Parents and Families Information for parents and family members about early childhood education. Date: _____ Full Medi-Cal benefits were granted pending verification of immigration status. Statewide Administrative Manual (SAM) section Privacy 5310 et seq. Exciting news - CDSS alumnus Patrick Bayer will be taking up a full professor position at the University of Glasgow in May. Application for Registration as a School Audiometrist - PM 101 This course reviews monitoring requirements, staffing, completing monitoring reports, and conducting the five-day reconciliation. ApplicpatoiCall Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). 2. 2022-2023 CACFP Capacitacin anual obligatoria (CDSS-110) Estado actual. That's what a next generation of #cdss look like. Click the download button to access the Contract Data Summary Sheet for all other contract types (not Fire, Police or Schools). CDA Forms; Information Security; Program Memos; MSSP Newsletter. Your Email address. (916) 440-7370, 711 (California State Relay) Email: CivilRights@dhcs.ca.gov. Your Organization. **Due to browser constraints please download forms for full functionality. Este curso est diseado para el personal que regresa del Programa de Alimentos para el Cuidado de Nios y Adultos (CACFP) y revisar los reglamentos y procedimientos del CACFP para ayudar a los operadores del CACFP . Failure to provide requested information may result in a denial of services. Health and Safety Code section 1500 et seq. The California Department of Social Services (CDSS) Privacy Notice on Collection covers our practices regarding personal information collected when completing applications and forms (online or hardcopy) for our various programs. For Spanish forms beginning with the following letters click below: A | B | C | D | E | F | G | H | I | J | K | L, Copyright 2023 California Department of Social Services, Spanish forms beginning with the letters M through Z, AAP 1 (9/09) - Request For Adoption Assistance Program Benefit, AAP 3 (2/22) - Reassessment Information - Adoption Assistance Program, AAP 5 (9/18) - Adoptions Assistance Program Independent Adoptions Program, AAP 6 (9/18) - Adoption Assistance Program Negotiated Benefit Amount and Approval, AAP 7 (12/17) - Adoptions Assistance Program Statement Of Acknowledgement, AAP 8 (9/18) - Adoption Assistance Program Nonrecurring Adoption Expenses Agreement, AAP 9A (5/21) - Adoption Assistance Program (AAP)Level Of Care Rate Determination Protocol Matrix, AAP 10 (10/21) -Prospective Or Adoptive Parent(s) Level Of Care (LOC) Reporting Tool, ABCDM 228 (6/99) - Applicant's Authorization For Release Of Information, ABCD 239.7A (8/01) - Notice Of Administrative Disqualification California Work Opportunity And Responsibility To Kids (CalWORKs) Program, ABCD 478A (5/20) - Disqualification Consent Agreement California Work Opportunity And Responsibility To Kids (CalWORKs) Program, ABCDM 229 (1/23) -Applicant/Recipients Authorization For Release Of Information To Community-Based Organization (CBO) In BenefitsCal, AD 1A (4/22) - Parental Consent To Adoption(In Or Out-Of-California), AD 1F (4/15) - Parental Consent To Adoption Outside California In Armed Forces - Independent Adoption Program, AD 2A/2B (5/11) - Stepparent Adoption (Consent to Adoption by a Parent in or outside of California Giving Custody to Husband or Wife or Domestic Partner of Other Parent), AD 2D (3/08) - Stepparent Adoption Consent To Adoption By Parent Outside California In Armed Forces Giving Custody To Husband Or Wife Or Domestic Partner Of Other Parent, AD 9 (11/07) - Independent Adoption Questionnaire, AD 20 (4/15) - Refusal To Give Parental Consent To Adoption - Independent Adoptions Program, AD 20B (5/15) - Refusal To Give Consent To Adoption - Alleged Natural Father, Independent Adoption Program, AD 22 (7/02) - Health Facility Minor Release Report, AD 65 (2/02) - Parent's Authorization For Medical And Surgical Care, AD 67 (5/15) - Information about The Birth Mother - Agency And Independent Adoptions Program, AD 67A (7/15) - Information About The Birth Father - Agency And Independent Adoptions Program, AD 72 (4/22) - Adoption Facilitator Complaint Form, AD 90 (6/13) - Supporting Information For Issuance Of California Department Of Social Services Acknowledgement And Confirmation Of Receipt Of Child Freeing Documents, AD 100 (7/10) - Authorization For Use And/Or Disclosure of Health Information Independent Adoption Program, AD 100A (3/08) - Authorization For Use And/Or Disclosure Of Health Information Agency Adoption Program, AD 165 (3/15) - Presumed Father's Consent To Adoption When Denying He Is The Biological Father (In or Out-of-California), AD 501 (6/14) - Relinquishment In or Out-of-County (Birth Mother/Biological Father/Presumed Father in California), AD 501A ENG/SP (9/14) - Relinquishment Out-of-State (Birth Mother/Biological Father/Presumed Father), AD 504 (5/15) - Relinquishment Out of State In Armed Forces (Birth Mother/Biological Father/Presumed Father), AD 508 (7/13) - Rescission Request/Rescission Of Relinquishment, AD 512 (1/14) - Psychosocial And Medical History Of Child, AD 521 (8/11) - Application For Adoption Of A Child, AD 583 ENG/SP (5/15) - Relinquishment In Or Out Of County - Presumed Father Denies He Is The Birth Father, AD 584 ENG/SP (8/12) - Relinquishment Out of State - Presumed Father Denies He is the Birth Father, AD 586 (7/14) - Relinquishment In or Out-of-County (Alleged Natural Father In California), AD 588 (4/15) - Denial Of Paternity By Alleged Natural Father - In Or Out Of California - Agency And Independent Adoptions Program, AD 590 (4/15) - Waiver Of Right To Further Notice Of Adoption Planning (Alleged Natural Father In Or Out Of California) - Agency And Independent Adoptions Program, AD 590A (6/15) - Waiver Of Right To Further Notice Of Adoption Planning - Presumed Father In Or Out Of California - Agency And Independent Adoptions Program, AD 591 (12/14) - Relinquishment Out-of-State (Alleged Natural Father), AD 593 (5/22) - Relinquishment Out of State in Armed Forces (Alleged Natural Parent), AD 594 (3/15) - Alleged Natural Father's Consent To Adoption (In Or Out Of California), AD 842 (3/17) - Alleged Father's Consent To Adoption (Outside California In The Armed Forces), AD 859 (8/15) - Parental Consent To Adoption Of Indian Child (In Or Out-Of-California) - Independent Adoptions Program, AD 860 (8/15) - Presumed Father's Consent To Adoption Of Indian Child (In Or Out-Of-California) - Independent Adoptions Program, AD 861 (8/15) - Consent To Adoption Of Indian Child By Alleged Father (In Or Out Of California) - Independent Adoption Program, AD 862 (3/12) - Relinquishment Of An Indian Child Out-Of-State (Alleged Natural Father), AD 863 (9/12) - Relinquishment Of Indian Child Out of State - Birth Mother/Presumed Father, AD 864 (3/08) - Relinquishment Of An Indian Child In Or Out-Of-County - Birth Mother/Presumed Father In California, AD 866 (10/14) - Relinquishment Of An Indian Child In Or Out-of-County - Presumed Father Denies He Is The Birth Father In California, AD 867 (3/08) - Relinquishment of an Indian Child - Out-of-State - Presumed Father Denies He is the Birth Father, AD 868 (8/14) - Relinquishment Of Indian Child - In/Out of County - Alleged Natural Father In California, AD 880 (1/21) Declaration Of Birth Parent - Agency And Independent Adoptions Program, AD 885 (3/14) - Mother Or A Biological/Presumed Father Of A Child Who Is Not Detained, A Juvenile Court Dependent In Out-of-home Care, Or The Ward Of A Legal Guardian, AD 885A (11/21) -Statement of Understanding - Parent or a Presumed Parent of a Child Who Is Detained, a Juvenile Court Dependent in Out-of-Home Care, or The Ward of a Legal Guardian, AD 885C (2/15) - Statement of Understanding Agency Adoptions Program - Alleged Natural Father Of The Child Who Is Not Detained, A Juvenile Court Dependent In Out-Of-Home Care, Or The Ward Of A Legal Guardian, AD 885D (11/21) -Statement of Understanding - Alleged Parent of a Child Who is Detained, a Juvenile Court Dependent in Out-of-Home Care, or the Ward of a Legal Guardian, AD 887 (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Gave Physical Custody (Custodial Parent) Of The Child To The Petitioner(s), AD 887A (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Did Not Give Physical Custody (Non-Custodial Parent) Of The Child To The Petitioner(s), AD 887B (3/18) - Statement Of Understanding Independent Adoptions Program - Alleged Father, AD 899 (3/08) - Statement of Understanding - Mother or a Presumed Father of the INDIAN Child Who is Not Detained, a Juvenile Court Dependent in Out-of-home Care, or a Ward of a Legal Guardian, AD 899A (11/21) - Statement of Understanding - Mother or a Presumed Father of an Indian Child Who is Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian, AD 899C (3/06) - Statement Of Understanding - Alleged Natural Father of the INDIAN Child Who is Not Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian, AD 899D (11/21) - Statement Of Understanding -Alleged Parent of an INDIAN Child Who is Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian, AD 900 (8/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Gave Physical Custody (Custodial Parent) Of The INDIAN Child To The Petitioner(s), AD 900A (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Did Not Give Physical Custody (Non-Custodial Parent) Of The INDIAN Child To The Petitioner(s), AD 900B (3/18) - Statement Of Understanding Independent Adoptions Program - Alleged Father Of An INDIAN Child, AD 902 (2/22) - Consent For Arranging Contact, AD 904A (8/20) - Waiver Of Rights To Confidentiality For Siblings, AD 904B (9/20) - Waiver Of Rights To Confidentiality For Siblings Under The Age Of 18, AD 907 (7/10) - Adoptive Placement Agreement, AD 908 (5/22) - Adoptions Information Act Statement, AD 918 (11/03) - Family Assessment Questionnaire II, AD 924 (6/22) - Independent Adoption Placement Agreement - Independent Adoptions Program, AD 925 (8/15) - Independent Adoption Placement Agreement - Indian Child - Independent Adoptions Program, AD 926 (1/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Places The Child With The Prospective Adoptive Parent(s), AD 927 (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Places The Indian Child With The Prospective Adoptive Parent(s, AD 928 (7/02) - Revocation Of Consent Independent Adoption Program, AD 929 (9/18) - Waiver Of Right To Revoke Consent Independent Adoption Program - Independent Adoptions Program, AD 929A (12/16) - Waiver Of Right To Revoke Relinquishment Agency Adoption Program, AD 931 (2/20) - Independent Adoption Of A Foreign-Born Child - Statement Of Acknowledgment, AD 933 (12/20) - Intercountry Readoption Acknowledgment, AD 4317 (3/20) - Revocation Of Relinquishment, AD 4310 (8/07) - Adoption Programs Notice Required By Information Practices Act, AD 4320 (6/22) - Adoption Assistance Program (AAP) Agreement, AD 4324 (2/21) - Adoption Questionnaire I, AD 4328 (3/06) - Authorization For Release Of Personal Items, AD 4336 (4/15) - Presumed Father's Consent To Adoption When Denying He Is The Biological Father (Outside California In Armed Forces) - Independent Adoption Program, AD 4337 (10/21) - Criminal Record Statement, AD 4339 (12/14) - Relinquishment Out of State (Birth Mother/Biological Father/Presumed Father), ADM 36 (6/99) - Medical Report Regarding Child To Be Adopted, ADSA 1 (3/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits, ADSA 1A (5/21) - Assistance Dog Special Allowance (ADSA) Application For Renewal Of Benefits, ADSA 1AL (11/21) - Assistance Dog Special Allowance (ADSA) Application For Renewal Of Benefits, ADSA 1B (6/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits For Recipients Of Social Security Disability Insurance (SSDI) Benefits, ADSA 1BL (7/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits For Recipients Of Social Security Disability Insurance (SSDI) Benefits, ADSA 1L (5/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits, ADSA 2 (10/21) Your Hearing Rights Under The Assistance Dog Special Allowance (ADSA) Program, ADSA 2L (12/21) Your Hearing Rights Under The Assistance Dog Special Allowance (ADSA) Program, ADSA 3 (10/21) - Assistance Dog Special Allowance (ADSA) Enclosure, ADSA 3L (11/21) - Assistance Dog Special Allowance (ADSA) Enclosure, AR 2 (11/13) - Reporting Changes For CalWORKs And CalFresh, AR 2 SAR (3/15) - Reporting Changes For CalWORKs And CalFresh, AR 3 (2/15) - Mid-Year Status Report For CalWORKs and CalFresh, ARC 1 (4/22) - Statement Of Facts Supporting Eligibility For The Approved Relative Caregiver (ARC) Funding Option Program, ARC 1A (11/16) Rights, Responsibilities, And Other Important Information, ARC 2 (11/16) - Redetermination: Statement Of Facts Supporting Eligibility For The Approved, CAS 854 (4/15) - Agency Adoption Fee - Reduction Request, CCD 21 (8/22) - Parent Plan For Seeking Employment (PPSE), CCD 27 (8/22) - Statement Of Parental Incapacitation, CCD 35 (8/22) - Educational Programs or Vocational Training Verification for Parent or Caretaker Attending Educational Programs or Receiving Vocational Training, CCP 1 (3/15) - Declaration of Exemption from Trustline Registration and Health and Safety Self-Certification, CCP 4 (8/21) - Health And Safety Self-Certification (For license-exempt providers), CCP 6 (8/99) - Health And Safety Checklist, CCP 7 (10/19) - CalWORKs Child Care Request Form And Child Care Payment Rules, CCP 8 (10/19) - CalWORKs Stage One Child Care Authorization Form, CCP 2145 (5/04) - CalWORKs Child Care Reimbursement Report, CD 9600 (12/99) - Confidential Application For Child Development Services And Certification Of Eligibility, CF 1 (10/14) - Notice To All CalFresh Recipients - Important Please Read, CF 10 (12/13) - Dependent Care Cost Affidavit, CF 11 (9/21) - Notice To All CalFresh Recipients- Important - Please Read - Use Starting October 1, 2021, CF 11 (9/22) - Notice To All CalFresh Recipients, CF 18 ENG/SP (2/14) - Important Information, CF 20 (2/14) - You Do Not Owe Anything For Receiving CalFresh Benefits, CF 28 Coversheet (2/14) - CalFresh Program Restricted Account Coversheet - Important To Know, CF 28A (2/14) - CalFresh Program Restricted Account Agreement Part A, CF 28B (2/14) - CalFresh Program Restricted Accounting Agreement part B, CF 29 (10/13) - CalFresh Recertification Appointment Letter, CF 29A (2/14) - CalFresh Initial Appointment Letter, CF 29B (2/14) - CalFresh Initial On-Demand Appointment Letter, CF 29C (2/14) - CalFresh Recertification Appointment Letter, CF 29D (2/14) - CalFresh Recertification On-Demand Appointment Letter, CF 31 (6/19) - CalFresh Supplemental Form For Special Medical Deductions, CF 32 (6/13) - CalFresh Request For Contact, CF 34 (12/20) CalFresh Notice of Change: Semi-Annual Reporting Eliminated, CF 37 (11/16) - Recertification For CalFresh Benefits, CF 100 (11/20) - CalFresh Request For Authorized Representative Drug Or Alcohol Treatment Center Resident, CF 101 (11/20) - CalFresh Request For Authorized Representative, CF 285 (4/21) - Application For CalFresh Benefits, CF 285A (11/21) - Application For CalFresh Benefits, CF 285LP (4/21) - Application For CalFresh Benefits, CF 303 (8/19) - Replacement Or Supplement Affidavit/Authorization, CF 304A (9/20) - Important Information About Your CalFresh Benefits - CalFresh Water Pilot, CF 304B (9/20) -Notice Of Approval For The CalFresh Water Pilot, CF 304C (9/20) -Notice Of Discontinuance For The CalFresh Water Pilot, CF 304D (10/22) - Notice Of CalFresh Water Pilot Extension, CF 377.1 (5/20) - Notice Of Approval For CalFresh Benefits, CF 377.1A (8/21) - Notice Of Denial Or Pending Status, CF 377.1A LP (8/21) - Notice Of Denial Or Pending Status, CF 377.1LP (5/20) - Notice Of Approval For CalFresh Benefits, CF 377.11 (6/18) - CalFresh Time Limit Notice - Failure To Meet The Able-Bodied Adults Without Dependents (ABAWDs) Work Requirement, CF 377.11A (6/18) - CalFresh Time Limit Notice - Expiration Of Three Consecutive Months For Able-Bodied Adults Without Dependents (ABAWDs), CF 377.11B (6/18) - CalFresh Countable Month Letter - Use Of Countable Month For Able-Bodied Adults Without Dependents (ABAWDs), CF 377.11C (1/20) - CalFresh Informational Notice - CalFresh Time Limit For Able-Bodied Adults without Dependents (ABAWDs), CF 377.11E (1/20) CalFresh Able-Bodied Adult Without Dependents (ABAWD) Time Limit Exemption Screening Form, CF 377.2 (9/18) - CalFresh Notice Of Expiration Of Certification, CF 377.2B (10/20) - CalFresh Notice Of Expiration Of Certification For Households With Only Elderly And/Or Disabled Members, CF 377.2C (12/20) - CalFresh Notice Of Expiration Of Certification For Households With Only Elderly And/Or Disabled Members, CF 377.2D (3/18) - CalFresh Notice Of Status Change For Households With Only Elderly And/Or Disabled Members, CF 377.4 CR (1/14) - CalFresh Notice Of Change For Change Reporting Households, CF 377.4 SAR (6/13) - CalFresh Notice Of Change For Semi-Annual Reporting Households, CF 377.4A (2/14) - CalFresh Notice Of Change (Non-Citizen), CF 377.5 SAR (9/13) - CalFresh Mid-Certification Period Status Report, CF 377.6 (8/13) - Information/Verification Needed, CF 377.7A (2/14) - Notice Of Administrative Disqualification, CF 377.7A1 (2/14) - Request For Restoration Of CalFresh Benefits After Administrative, CF 377.7B (4/18) - CalFresh Overissuance Notice - Inadvertent Household Errors (IHE) Only, CF 377.7B LP (2/18) - CalFresh Overissuance Notice - Inadvertent Household Errors (IHE) Only, CF 377.7B1 (10/17) - CalFresh Repayment Notice For Inadvertent Household Errors Only Final Notice, CF 377.7B1 LP (2/18) - CalFresh Repayment Notice - Inadvertent Household Errors Only Final Notice - Large Print, CF 377.7C (2/14) - CalFresh Repayment Agreement For Inadvertent Household Errors Only, CF 377.7D (1/14) - CalFresh Overissuance Notice For Administrative Errors (AE) Only, CF 377.7D1 (1/14) - CalFresh Overissuance Notice For Administrative Errors (AE) Only, CF 377.7D2 (10/17) - CalFresh Repayment Final Notice - County Administrative Error (AE), CF 377.7D2 LP (2/18) - CalFresh Repayment Final Notice - County Administrative Error (AE), CF 377.7D3 (10/17) - CalFresh Overissuance Notice For Administrative Errors (AE), CF 377.7D3 LP (6/18) - CalFresh Overissuance Notice For Administrative Errors (AE), CF 377.7E1 (1/14) - CalFresh Repayment Agreement For Administrative Errors Only, CF 377.7F (10/17) - CalFresh Overissuance Notice - Change From Inadvertent Household Error (IHE) To Intentional Program Violation (IPV), CF 377.7F LP (2/18) - CalFresh Overissuance Notice - Change From Inadvertent Household Error (IHE) To Intentional Program Violation (IPV), CF 377.7F1 (10/17) - CalFresh Repayment Final Notice - Intentional Program Violation (IPV), CF 377.7F1 LP (2/18) - CalFresh Repayment Final Notice - Intentional Program Violation (IPV), CF 377.7G (3/18) - CalFresh Intentional Program Violation (IPV) Notice - Due To Trafficking, CF 377.9 (8/20) - Notice Of Back CalFresh Benefits, CF 377.9LP (8/20) - Notice Of Back CalFresh Benefits, CF 377.11D (1/20) CalFresh Discretionary Exemption For Able-Bodied Adults Without Dependents (ABAWDs), CF 385 (10/15) - Application For Disaster CalFresh, CF 386 (2/14) - CalFresh Notice Of Missed Interview, CF 387 (5/14) - CalFresh Request For Information, CF 388 (8/13) - CalFresh Notice Of Restoration Approval, CF 389 (2/14) - Notice Of Denial Of Restoration, CF 390 (5/19) Notice of Approval/Denial For Disaster CalFresh, CF 478 (2/14) - Disqualifiction Consent Agreement CalFresh Program, CF 502 (2/23) -Notice To All CalFresh Recipients - End Of CalFresh Emergency Allotments, CF 886 (8/22) - CalFresh Notice Of Work Rules, CF 1239 (12/20) - CalFresh Notice Of Approval/Denial/Termination Transitional Benefits, CF 6177 (10/22) - CalFresh Student Exemption Screening Form, CF SSA 1 (9/20) - Information For Households Applying For CalFresh With The Social Security Administration, CF SSA 1LP (9/20) - Information For Households Applying For CalFresh With The Social Security Administration, CRF 01 (10/20) - Coronavirus Relief Fund (CRF) Certification Of Eligibility, CL 1 (4/99) - Cal-Learn Registration Program Information Orientation Appointment, CL 2 (4/99) - Cal-Learn PROGRAM REQUIREMENTS, CL 3 (4/99) - Cal-Learn Notice Of A Participation Problem, CL 4 (4/99) - Cal-Learn Notice To Parent/Legal Guardian Of Cal-Learn Participant, CL 8 (3/99) - Cal-Learn Notice Of Report Card Submittal Schedule, CL 9 (3/99) - Cal-Learn Notice Of Good Cause Determination, CL 10 (4/99) - Cal-Learn Notice Of Exemption/Deferral, CL 11 (4/99) - Cal-Learn Notice Of Incomplete Grades, CR 6181 (11/20) - Interpreter Services Statement And Confidentiality Agreement, CSFP 001 (7/22) - Commodity Supplemental Food Program (CSFP) Participant Application, CSFP 006 (7/22) - Commodity Supplemental Food Program (CSFP) Notice Of Action, CTRI 01 (10/20) - California Tax Return Information (CTRI) Notification To Client, CW 2.1 N A (8/04) - Notice And Agreement For Child, Spousal And Medical Support, CW 4 (6/02) - Immediate Need Payment Request, CW 5 (7/01) - Veterans Benefits Verification and Referral, CW 8 (11/14) - Statement of Facts For An Additional Person, CW 8A (12/14) - Statement Of Facts To Add A Child Under Age 16, CW 10 (7/01) - Notice of Withdrawn Application, CW 13 (9/02) - Caretaker Relative Agreement, CW 23 (3/00) - Senior Parent - Statement Of Facts, CW 25 (7/01) - Supplemental Statement Of Facts - Minor Parent, CW 25A (2/13) - Payee Agreement For Minor Parent, CW 42 (10/21) - Statement of Facts - Homeless Assistance, CW 43 (3/00) - CalWORKs Applicant Choice Form Immediate Need Payment/Expedited Grant, CW 51 (10/11) - Child Support - Good Cause Claim For Noncooperation, CW 52 (7/18) - Changes To The California Work Opportunity And Responsibility To Kids (CalWORKs) Assistance Unit And Child Support Rules, CW 52 (10/20) California Work Opportunity And Responsibility To Kids (CalWORKs) Child Support Instead Of Cash Grant Option, CW 60 (5/01) - Release Of Information - Financial Institution, CW 61 (7/01) - Authorization to Release Medical Information, CW 63 (11/20) - Request For Income And/Or Resource Verification, CW 71 (3/00) - Statement Of Cash Aid Mother And Unrelated Adult Male (UAM), CW 74 (9/19) - Permanent Housing Search Document, CW 80 (2/18) - Self-Certification Form For Motor Vehicles - CalWORKs, CW 82 (3/00) - Important Information About This Agreement, CW 86 (10/21) - Agreement - Restricted Account California Work Opportunity And Responsibility To Kids (CalWORKs) Program, CW 87 (6/02) - Reinforming Letter/Add a Person(s) Program, CW 88 (6/11) - Diversion Services Agreement CalWORKs Program, CW 88 Coversheet (6/11) - You May Be Eligible For Diversion Services, CW 89 (2/03) - Application Withdrawl Request, CW 101 (7/17) - CalWORKs Immunization Rules, CW 103 (11/09) - Multilingual - Transitional Medi-Cal, CW 2103 (6/16) - Reminder For Teens Turning 18 Years Old, CW 2166 (12/20) - Multilingual Work Really Pays! Community Care Licensing Adult and Senior Care Program 744 P Street, MS 9-14-820 Sacramento, CA 95814 Telephone: (916) 657-2592 Fax: (916) 653-9335 2074-Inst. (This form is not to be sent home or given to parents to complete.) El propsito de las visitas y las cartas es asegurar que los requisitos del Programa se estn cumpliendo y que los servicios autorizados sean necesarios para que usted permanezca en su hogar de una manera segura. Toma este curso. Language Access Complaint Form. Join to apply for the ASSOCIATE GOVERNMENTAL PROGRAM ANALYST role at California Department of Social ServicesASSOCIATE GOVERNMENTAL PROGRAM ANALYST role at Calendar Fiscal Year 2019-20 EESD-9730 (XLS) Privacy Notice on Collection Termination of Service for . Multipurpose Senior Services Program. Tips for Using Adobe PDF Files, Copyright 2023 California Department of Social Services, ICPC 100A Instructions (7/20) Instructions For Completing Form ICPC 100A Interstate Compact On The Placement Of Children Request, ICPC 100A (11/20) Interstate Compact On The Placement Of Children Request, ICPC 100B Instructions (7/20) Instructions For Completing Form ICPC 100B Interstate Compact Report On Childs Placement Status, ICPC 100B (7/20) Interstate Compact On The Placement Of Children Report On Childs Placement Status, IHSS-E 002 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Provider For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances, IHSS-E 003 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances, IHSS-E 004 (4/17) - In-Home Supportive Services Program Notice Of Non-Receipt Of Exemption From Workweek Limits Provider Agreement (APD 006), IHSS-E 005 (1/17) - In-Home Supportive Services Program Notice Of Ineligibility To Request Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) - Provider, IHSS-E 006 (4/17) - In-Home Supportive Services Program Notice To Provider Of Expiration Of Exemption From Workweek Limits, IHSS-E 007 (4/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Providers Expiration Of Exemption From Workweek Limits, KG 1 (12/11) - Kin-GAP Mutual Agreement For 18 Year Olds, KG 2 (1/11) - Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (Kin-GAP) Program, KG 3 (12/11) - Kin-GAP Mutual Agreement For Nonminor Former Dependents, KG 4 (2/14) - Kinship Guardianship Assistance Payment (Kin-GAP) Program - Nonrecurring Legal Guardianship Expenses Agreement, KG 5 (2/14) - Kinship Guardianship Assistance Payments (Kin-GAP) Program Nonrecurring Legal Guardianship Expenses Form, LIC 00 (8/17) - Conversion to Resource Family: Release of Information, LIC 00A (2/17) - Conversion - Resource Family Application, LIC 01A (9/21) - Resource Family Application, LIC 01C (7/16) - Resource Family Application-Confidential, LIC 03 (8/21) - Resource Family Home Health And Safety Assessment Checklist Document For Agency Use Only, LIC 05A (8/21) - Resource Family Approval Certificate, LIC 12 (8/21) - Resource Family Approval Document Alternative Plan (DAP), LIC 102 (9/99) - Sanitation Inspection Request, LIC 107 (9/00) - Applicant Fingerprint Follow-Up Request, LIC 125 (3/21) - Entrance Checklist - Child Care Centers, LIC 126 (3/21) - Entrance Checklist - Family Child Care Homes, LIC 165 (8/07) - Board Of Directors Statement, LIC 178 (12/15) - Deficiency/Penalty Review, LIC 184 (5/00) - Notification Of Incomplete Application, LIC 184A (1/08) - Notification Of Incomplete Foster Family Home Application, LIC 184B (3/22) - Notification Of Incomplete Application - Family Child Care Home, LIC 184C (3/22) - Notification Of Incomplete Application (NOIA) Child Care Centers -Pre-30-Day NOIA, LIC 184D (3/22) - Notification Of Incomplete Application (NOIA) Child Care Centers - 30-Day NOIA, LIC 184E (3/22) - Notice Of Incomplete Application (NOIA) Changes To Corporate Status, LIC 186A (10/04) - Orientation Meeting Family Child Care Home, LIC 192 (7/03) - Notification Of Initial Application Denial, LIC 195 (8/19) - Notice Of Operation In Violation Of Law, LIC 195A (8/19) - Notice Of Operation In Violation Of Law - Family Child Care Home, LIC 198 (1/22) - Child Abuse Central Index Check For County Licensed Facilities, LIC 198B (8/21) - Out-Of-State Child Abuse/Neglect Report Request, LIC 200 (2/11) - Application For A Community Care Facility or Residential Care Facility For The Elderly License, LIC 200TM (6/18) - Temporary Manager Application For Provisional License, LIC 200A (2/17) - Application for a Child Care Center License, LIC 201F (2/01) - Annual License Fee Notice - County, LIC 215TM (11/18) - Temporary Manager Candidate List Application Information, LIC 216TM (11/18) - Temporary Manager Appointment Applicant Information, LIC 229 (9/99) - Certificate Of Approval (For Certified Family Homes), LIC 279 (2/23) - Application For A Family Child Care Home License, LIC 279A (5/17) - License Application And Instructions For Family Child Care Homes, LIC 279B (1/22) - Current Children In Your Home - Application For A Family Child Care Home License, LIC 281 (9/04) - Application Instructions for A Facility License, LIC 281A (1/07) - License Application And Instructions For Child Care Centers, LIC 281D (1/17) - Application And Supporting Documentation Checklist Foster Family Agency, LIC 281E (1/17) Application And Supporting documentation Checklist Short - Term Residential Therapeutic Program, LIC 282 (1/22) - Affidavit Regarding Liability Insurance For Family Child Care Home, LIC 283 (4/10) - Foster Family Home Application, LIC 283A (12/07) - Foster Family Home Application Instructions, LIC 300A (01/22) - Removal Confirmation - Exemption Needed, LIC 300B (9/03) - Removal Confirmation - Denial, LIC 300C (9/03) Removal Confirmation Rescinded, LIC 300D (9/03) - Removal Confirmation Non-Exemptible, LIC 300E (12/03) - Removal Confirmation - County, LIC 301A (8/07) - Reference Request - Adoption Facilitator, LIC 301B (8/07) - Reference Request - Long-Term Care Ombudsman Program, LIC 301E (10/22) - Reference Request - Exemption, LIC 306 (3/01) - Reporting Requirements By Licensees To The State Department Of Social Services, LIC 308 (11/02) - Designation Of Facility Responsibility, LIC 309 (6/01) (PUBLIC) - Administrative Organization, LIC 311A (2/22) - Records To Be Maintained At The Facility - Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children, LIC 311B (4/05) - Records To Be Maintained By The Facility - Group Homes, LIC 311C (4/05) - Records To Be Maintained At The Facility - Adult Residential, LIC 311D (2/22) - Forms/Records To Keep In Your Family Child Care Home, LIC 311E (4/05) - Records To Be Maintained At The Facility - Small Family Home And Foster Family Home, LIC 311F (4/05) - Records To Be Maintained At The Facility - Residential Care Facility For The Elderly, LIC 313 (12/01) - Evidence Of Program Consultant, LIC 400 (1/99) - Affidavit Regarding Client/Resident Cash Resources, LIC 401 (3/01) - Monthly Operating Statement, LIC 401A (3/99) - Supplemental Financial Information, LIC 403A (9/11) - Balance Sheet Supplemental Schedule, LIC 404 (7/99) - Financial Information Release And Verification, LIC 405 (8/01) - Record Of Client's/Resident's Safeguarded Cash Resources, LIC 406 (5/13) - Client/Resident Cash Sheet, LIC 421A (6/22) - Civil Penalty Assessment (Unlicensed Facility), LIC 421BG (5/19) - Civil Penalty Assessment Caregiver Background Check, LIC 421CC (6/22) - Civil Penalty Assessment Child Care, LIC 421D (ASC) (6/17) - Civil Penalty Assessment Death/Serious Bodily Injury/Physical Abuse (ASC), LIC 421D (CC) (8/22) - Civil Penalty Assessment Death/Serious Injury/Physical Abuse (Child Care), LIC 421D (CRP) (6/17) - Civil Penalty Assessment Death/Serious Bodily Injury/Physical Abuse (CRP), LIC 421FC (7/17) - Civil Penalty Assessment Failure To Correct And Repeat Violations, LIC 421IM (7/17) - Civil Penalty Assessment Immediate $500 And Repeat Violations, LIC 422 (9/11) - Notice Of Civil Penalties Due, LIC 424 (1/03) - Record Of Client's Cash Resources For Change Of Licensee, LIC 503 (3/99) - Health Screening Report - Facility Personnel, LIC 507 (1/00) - Facilities Staff Work Schedule, LIC 508 (7/21) - Criminal Record Statement & Out-Of-State Disclosure, LIC 508 O-O-S (2/20) - Out-Of-State Disclosure, LIC 508A (3/11) - Criminal Record Statement - Adoption Facilitator, LIC 508B (3/11) - Criminal Record Statement - Long-Term Care Ombudsman Program, LIC 508D (11/22) - Out-Of-State Disclosure And Criminal Record Statement, LIC 601 (8/08) - Identification And Emergency Information, LIC 602 (7/22) - Physician's Report For Community Care Facilities, LIC 602A (8/11) - Physician's Report For Residential Care Facilities For The Elderly (RCFE), LIC 603 (6/22) - Preplacement Appraisal Information, LIC 604 (10/05) - Admission Agreement Guide For Residential Facilities, LIC 604A (2/05) - Admission Agreement For Residential Care Facilities For The Elderly, LIC 605A (7/22) - Release Of Client/Resident Medical Information, LIC 606 (8/18) - Residential Care Facility For The Elderly Disclosure Worksheet, LIC 610 (10/03) - Emergency Disaster Plan For Child Care Centers, LIC 610A (01/22) - Emergency Disaster Plan For Family Child Care Homes, LIC 610B (6/02) - Emergency Plan For Foster Family Homes, LIC 610C (10/03) - Emergency Disaster Plan For Children's Residential Facilities (Except Foster Family Homes), LIC 610D (12/21) - Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities, LIC 610E (3/19) - Emergency Disaster Plan For Residential Care Facilities For The Elderly, LIC 613 (12/02) - Personal Rights Adult Residential Care Facilities, LIC 613A (8/08) - Personal Rights - Child Care Centers, LIC 613B (6/22) - Personal Rights Childrens Residential Facilities, LIC 613C (1/19) - Personal Rights Of Residents In Publicly Operated Residential Care Facilities For The Elderly, LIC 613C-2 (1/19) - Personal Rights Of Residents In Privately Operated Residential Care Facilities For The Elderly, LIC 621 (4/99) - Client/Resident Personal Property And Valuables, LIC 622 (9/19) - Centrally Stored Medication And Destruction Record, LIC 622A (6/17) - Medication Administration Record (MAR), LIC 622B (5/17) - Psychotropic Medication Administration Record (MAR), LIC 623 (5/01) - Group Planned Activities, LIC 624 (4/99) - Unusual Incident/Injury Report, LIC 624B (8/08) - Unusual Incident/Injury Report - Family Child Care Home, LIC 624 LE (12/22) - Law Enforcement Contact Report, LIC 625 (11/19) Appraisal/Needs and Services Plan, LIC 627 (9/08) - Consent For Emergency Medical Treatment - Child Care Centers Or Family Child Care Homes, LIC 627A (9/08) - Consent To A Medical Examination, LIC 627B (9/08) - Consent For Emergency Medical Treatment - Children's Residential Facilities, LIC 627C (4/00) - Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities, LIC 700 (10/19) - Identification And Emergency Information Child Care Centers/Family Child Care Homes, LIC 701 (8/08) - Physician's Report - Child Care Centers, LIC 701A (9/00) - Gastrostomy - Tube Care: Physician's Checklist (Child Care Facilities), LIC 701B (9/00) - Gastrostomy - Tube Care Consent/Verification (Child Care Facilities), LIC 702 (10/19) - Child's Preadmission Health History - Parent/Authorized Representative Report, LIC 808 (12/20) Plan For Epidemic Outbreak Specific to COVID 19 Mitigation Plan Report, LIC 809 (12/15) - Facility Evaluation Report, LIC 812 (8/06) - Detail Supportive Information, LIC 813 (11/99) - Facility Photography Report, LIC 856A (3/21) - Complaint Intake Notification, LIC 856B (3/21) - Complaint Determination Notification - Substantiated, LIC 856C (3/21) - Complaint Determination Notification - Unsubstantiated, LIC 856D (3/21) - Complaint Determination Notification - Unfounded, LIC 857 (8/06) - Children's Record Review, LIC 858 (10/99) - Client/Resident Records Review, LIC 858A (7/00) - Additional Child Records Review For Specialized Foster Care Homes, LIC 859 (8/06) - Review of Staff/Volunteer, LIC 860C (12/02) - Facility Review Index Foster Family Homes, LIC 861 (1/03) - Prelicensing In-Home Interview, LIC 907 (5/00) - Transmittal For Processing, LIC 972 (5/00) - Individual Waiver/Exception Log, LIC 973 (4/03) - Documented Alternative Plan - Foster Family Homes (Bedrooms), LIC 974 (4/03) - Documented Alternative Plan - Foster Family Homes (Telephones), LIC 986A (10/99) - Notice Of Revocation Action, LIC 989A (3/17) - Non-Confidential Records Request Form, LIC 995 (9/08) - Child Care Center - Notification Of Parents' Rights, LIC 995A (8/08) - Family Child Care Home - Notification Of Parents' Rights, LIC 995B (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Removal/Exclusion), LIC 995C (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Reinstatement), LIC 995D (5/03) - Family Child Care Home Explanation Of Removal/Exclusions And Reinstatement, LIC 995E (10/09) - Important Information For Parents, LIC 995F (10/09) - Caregiver Background Check Information, LIC 996 (5/99) - Agreement For Licensure Of Community Care Facility/Child Care Facility On Federal Property, LIC 996A (5/01) - Agreement For Licensure Of Community Care Facility/Child Care Facility On Indian Reservations, LIC 997 (10/99) - Agreement By Licensee/Applicant On Federal Property, LIC 997A (4/01) - Agreement By Licensee/Applicant On Indian Reservations, LIC 999 (3/99) - Facility Sketch (Floor Plan), LIC 999A (2/05) - Facility Sketch (Floor Plan) - Family Child Care Home, LIC 9011A (4/05) - County Licensing Administrative Action Personnel Flagging Attachment, LIC 9011B (5/05) - CDSS Licensing Administrative Action Personnel Flagging Attachment, LIC 9020 (5/17) - Register Of Facility Clients/Residents, LIC 9020A (6/17) - Register Of Facility Residents - Residential Care Facilities For The Elderly, LIC 9029B (7/09) - Statement Of Facts Preparation Checklist, LIC 9031 (11/99) - Notice Of Temporary Suspension Order Of License, LIC 9040 (10/05) - Child Care Facility Roster, LIC 9054 (3/99) - Local Fire Inspection Authority Information, LIC 9058 (3/22) - Applicant/Licensee Rights, LIC 9059 (5/99) - Personal Property Procedures, LIC 9060 (2/00) - Resident Theft And Loss Record, LIC 9092 (2/11) - Fire Pre-Inspection/Consultation Request, LIC 9095 (6/99) - Evaluation Of Teacher Qualifications, LIC 9096 (2/00) - Evaluation Of Director Qualifications, LIC 9099 (12/16) - Complaint Investigation Report, LIC 9102TA (2/19) - Advisory Notes - Technical Assistance, LIC 9102TV (2/19) - Advisory Notes - Technical Violation, LIC 9106 (11/19) - Group Home Program Statement General Instructions, LIC 9106A (3/21) - Short-Term Residential Therapeutic Program, LIC 9108 (3/05) - Statement Acknowledging Requirement To Report Suspected Child Abuse, LIC 9111 (12/99) - Noncompliance Conference Summary, LIC 9112 (9/21) - Facility Compliance Plan, LIC 9118 (6/21) - Facility Inspection Checklist Checklist Child Care Centers, LIC 9119 (10/22) Facility Inspection Checklist Group Homes, LIC 9119 AA (7/22) - Facility Inspection Checklist Adoption Agency, LIC 9119 CCH (11/22) - Facility Inspection Checklist Community Crisis Home, LIC 9119 CN (8/22) - Facility Inspection Checklist Crisis Nurseries, LIC 9119 CTF (1/22) Facility Inspection Checklist Community Treatment Facility, LIC 9119 EBSH (4/22) - Facility Inspection Checklist Enhanced Behavioral Supports Homes, LIC 9119 TrSCF (12/22) - Facility Inspection Checklist Transitional Shelter Care Facility, LIC 9119 YHPC (4/22) - Facility Inspection Checklist Youth Homelessness Prevention Center, LIC 9120A (2/20) - Licensed Facility Inspection Checklist Adult Care Facilities, LIC 9121 (7/21) - Facility Visit Checklist Family Child Care, LIC 9122 (11/03) - Facility Visit Checklist Foster Family Home, LIC 9122A (7/20) Facility Inspection Checklist Small Family Home, LIC 9123 (2/20) - FacilityInspection Checklist - Residential Care Facility For The Elderly, LIC 9128 (5/22) - Foster Family Agency Program Statement, LIC 9139 (11/16) - Renewal Of Continuing Education Course Approval - Administrator Certification Program, LIC 9140 (11/16) - Request For Course Approval - Administrator Certification Program, LIC 9140A - Request to Add or Replace Instructor, LIC 9148 (9/00) - Earthquake Preparedness Checklist (EPC), LIC 9149 (8/14) - Family Child Care Home Property Owner/Landlord Consent Form, LIC 9150 (8/14) - Parent Notification - Additional Children in Care, LIC 9151 (8/14) - Property Owner/Landlord Notification Family Child Care Home, LIC 9158 (7/22) - Telecommunications Device Notification, LIC 9163 (3/21) - Request Live Scan Service - Community Care Licensing, LIC 9163B (11/22) - Request Live Scan Service - Long Term Care OMBUDSMAN, LIC 9165 (4/22) - Board Of Director Statement, LIC 9166 (2/01) - Nebulizer Care Consent/Verification (Child Care Facilities), LIC 9172 (8/01) - Functional Capability Assessment, LIC 9182 (1/23) - Criminal Background Clearance Transfer Request, LIC 9185 (8/08) - Foster Family Agency Certified Home, LIC 9187 (7/00) - Child Care Client Death Report, LIC 9188 (12/22) - Criminal Record Exemption Transfer Request, LIC 9198 (7/01) - Modified Comprehensive Visit Licensee Self-Assessment Staff Qualifications/Records Module Child Care Centers, LIC 9199 (7/01) - Modified Comprehensive Visit Licensee Self-Assessment Children's Records Module Child Care Centers, LIC 9200 (9/11) - Pre-Licensing Facility Evaluation Checklist, LIC 9201 (10/01) - Annual Regulation Compliance Checklist, LIC 9210 (5/06) - Quarterly County Exemption Report, LIC 9211 (9/21) - Request For Inactive Child Care License Status, LIC 9212 (10/05) - Consumer Awareness Information - Family Child Care, LIC 9213 (1/04) - Notice Of Site Visit By A Child Care Licensing Office Representative, LIC 9214 (12/22) - Application for Administration Certification - Administrator Certification Program, LIC 9216 (3/17) - Complaint And Type A Violation Log, LIC 9217 (5/22) - Pre-Licensing Readiness Guide - Family Child Care Home, LIC 9219 (3/16) - Crisis Nursery Monthly Report, LIC 9219A (3/16) - Crisis Day Care Sign-In, LIC 9221 (5/22) - Parent Consent For Administration Of Medications And Medication Chart, LIC 9222 (9/05) - Blood Glucose Testing Consent/Verification Child Care Facilities, LIC 9223 (4/17) - Child Care Advocate Program, LIC 9224 (8/08) - Acknowledgement Of Receipt Of Licensing Reports, LIC 9225 (4/10) - Pre-Placement Questionnaire, LIC 9226 (5/18) - Request For Training Approval: Mandated Child Abuse Reporter Training, LIC 9227 (8/20) - Individual Infant Sleeping Plan, LIC 9229 (7/21) - Licensing Program Manager (LPM) Checklist For Complaint Review, LIC 9230 (7/21) - Licensing Program Analyst (LPA) Checklist For Complaint Review, LIC 9233 (7/20) Facility Inspection Checklist Foster Family Agencies, LIC 9234 (7/20) Entrance Checklist Foster Family Agency, LIC 9235 (10/22) Facility Inspection Checklist Short Term Residential Therapeutic Program, LIC 9236 (7/20) Entrance Checklist Short Term Residential Therapeutic Program, LIC 9237 (7/20) Facility Inspection Checklist Transitional Housing Placement Program, LIC 9238 (7/20) Entrance Checklist Transitional Housing Placement Program, LIC 9239 (7/20) Entrance Checklist Group Home, LIC 9239 AA (12/22) Entrance Checklist Adoption Agency, LIC 9239 CCH (11/22) - Entrance Checklist - Community Crisis Homes, LIC 9239 CN (8/22) - Entrance Checklist - Crisis Nurseries, LIC 9239 CTF (01/22) - Entrance Checklist Community Treatment Facility, LIC 9239 EBSH (3/22) - Entrance Checklist Enhanced Behavioral Supports Homes, LIC 9239 TrSCF (8/22) - Entrance Checklist - Transitional Shelter Care Facility, LIC 9239 YHPC (4/22) - Entrance Checklist Youth Homelessness Prevention Center, LIC 9240 (7/20) Entrance Checklist Small Family Home, LIC 9241 (2/20) - Entrance Checklist Adult Care Facilities, LIC 9242 (9/19) - Entrance Checklist Residential Care Facilities For The Elderly, LIC 9263 (3/21) Form 1-1: Resident Population, LIC 9264 (3/21) Form 1-2: Annual Provider Fee, LIC 9265 (6/21) Form 5-1: Long-Term Debt Incurred In A Prior Year (Including Balloon Debt), LIC 9266 (3/21) Form 5-2: Long-Term Debt Incurred During Fiscal Year (Including Balloon Debt), LIC 9267 (3/21) Form 5-3: Calculation Of Long-Term Debt Reserve Amount, LIC 9268 (6/21) Form 5-4: Calculation Of Net Operating Expenses, LIC 9269 (3/21) Form 5-5: Annual Reserve Certification, LIC 9270 (9/22) Form 7-1: Report On CCRC Monthly Care Fees, LIC 9271 (6/21) Form 9-1: Calculation Of Refund Reserve Amount, LIC 9272 (11/21) Annual Report Checklist, LIC 9273 (5/22) Continuing Care Retirement Community Disclosure Statement, LIC 9275 (6/21) - External Water Sampler Self-Certification Form, LIC 9276 (7/21) Child Care Center Sampling Checklist Form, IC 9277LUA (8/21) - Guardian Licensee User Access Form, LIC 9279 (10/21) - Pre-licensing Entrance Checklist - Child Care Centers, LIC 9280 (10/21) - Pre-licensing Entrance Checklist - Family Child Care Homes, LIC 9281 (01/22)- Small Family Home Risk Assessment, LIC 9282 (5/22) Residential Infection Control Plan - Adult Residential Facilities, Enhanced Behavioral Supports Homes, Community Crisis Homes, Residential Care Facilities for the Elderly, Residential Care Facilities for the Chronically Ill, and Social Rehabilitation Facilities, LIC 9283 (5/22) - Infection Control Plan - Adult Day Programs. 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