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Fill in a Valid Lic 500 Form

The Lic 500 form is a critical document used by facilities in California to maintain an accurate roster of personnel and other adults residing within the facility. It ensures compliance with state regulations regarding criminal background checks and personnel changes. Timely completion and submission of this form are essential for proper licensing and operational oversight.

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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.

DATE

SPECIFY

NAME

JOB TITLE

DAYS AND HOURS ON DUTY

EMPL'D

DAYS

FROM

DAYS

FROM

DAYS

FROM

Licensee/Administrator

LIC 500 (11/03) (PUBLIC)

Page 1 of 2

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 __________________

NAME

DATE

EMPL'D

JOB TITLE

	SPECIFY			SPECIFY			SPECIFY
DAYS AND HOURS ON DUTY			DAYS AND HOURS ON DUTY			DAYS AND HOURS ON DUTY
DAYS	FROM	TO	DAYS	FROM	TO	DAYS	FROM	TO

Page 2 of 2

Document Information

Fact Name	Description
Purpose	The LIC 500 form is used to maintain a current roster of all personnel and adults residing in a facility.
Governing Laws	This form is governed by Sections 1522, 1568.09, 1569.17, and 1596.871 of the California Health and Safety Code.
Background Checks	Staff members listed on the form are subject to criminal background checks before employment or presence in the facility.
Exemptions	Some staff may be exempt from background checks, as indicated by the licensee or designated representative's signature.
Retention	A copy of the completed form must be retained in the facility's file for record-keeping purposes.
Submission	The original form must be sent to the licensing agency as required by regulations.
Facility Information	The form requires specific details about the facility, including its name, type, and facility number.
Staff Details	It includes sections for documenting staff names, job titles, and their days and hours on duty.

Lic 500 - Usage Guidelines

Completing the Lic 500 form is essential for maintaining an accurate record of personnel associated with a facility. This form ensures that the licensing agency has up-to-date information about staff members, including those who require background checks and those who are exempt. Following the steps below will help you fill out the form correctly.

Begin by filling in the NAME OF FACILITY at the top of the form.
Next, indicate the FACILITY TYPE and FACILITY NUMBER.
Complete the PREPARED BY section with your name and the DATE you are filling out the form.
In Section A, list all staff members who are subject to criminal background check requirements. For each person, provide the following details:

NAME
JOB TITLE
DAYS AND HOURS ON DUTY

Ensure you specify the DAYS EMPLOYED and the HOURS ON DUTY for each staff member.
Move to Section B, where you will list staff members exempt from criminal background check requirements. Again, provide the following information:

NAME
DATE EMPLOYED
JOB TITLE
DAYS AND HOURS ON DUTY

After filling in the required details, the licensee or designated representative must sign the form to verify the exemption status of the indicated persons.
Finally, write the DATE of the signature.
Submit the original form to the licensing agency and keep a copy for your facility's records.

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Dos and Don'ts

When filling out the Lic 500 form, attention to detail is crucial. Here are some important guidelines to follow:

Do ensure that all personnel listed are current and accurate.
Do include the license or certificate number for specialized staff, such as social workers.
Do report any changes in personnel to the licensing agency promptly.
Don't leave any sections of the form incomplete; every field is important.
Don't forget to retain a copy of the completed form in the facility file.
Don't overlook the requirement for a criminal background check for applicable staff members.

Common mistakes

Not Including All Personnel: Many people forget to list all staff members, including backup personnel, volunteers, and licensees. Ensure that everyone who is present in the facility is accounted for.
Omitting Criminal Background Check Information: It’s crucial to specify which staff members are subject to criminal background checks. Failure to do so can lead to compliance issues.
Incorrect Job Titles: Using incorrect or outdated job titles can create confusion. Double-check that each title accurately reflects the individual’s role within the facility.
Not Reporting Changes Promptly: If there are changes in personnel, they must be reported to the licensing agency as required. Delays can result in penalties.
Missing Signatures: The licensee or designated representative must sign the form. An unsigned form is incomplete and may not be accepted.
Failing to Retain a Copy: Always keep a copy of the completed Lic 500 form in the facility’s file. This is essential for record-keeping and future reference.
Inaccurate Dates: Ensure that the employment dates and hours on duty are accurate. Mistakes in this area can lead to misunderstandings about staff availability.
Not Specifying Coverage: In residential facilities, it’s important to show coverage for twenty-four-hour supervision. Failing to specify this can raise concerns during inspections.
Ignoring Specialized Staff Requirements: If there are specialized staff members, such as social workers, their license or certificate numbers must be included. This is often overlooked.

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