Set a password to access your documents anytime, You seem to be using an unsupported browser. Community Care Licensing Forms. Required for new building/renovations only. 195 N 1950 W Residential Care Facilities for the Chronically Ill. For every single segment, fill out the content requested by the software. The required forms are part of rule and cannot be changed. Call: (801) 538-4242 However, if you provide CDSS with any type of contact information, 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. Carmen Richins, who has been serving as the Office of Background Processing Director, is now the Interim Director of the Division of Licensing & Background Checks, and Simon Bolivar is the Director of the Office of Licensing under that division. Home > School Year Summer Fun FORMS Newsletter Gallery Community Care Licensing Forms . Certification of School Building Fire Safety Provisions CCL-5043 - Word, Self-Certification of Transportation Provisions for Centers CCL-5044 - PDF 1-855-323-DCFS(3237) They may be usedas posted here or you can create your own versions. Sort:Default. Title 22 Regulations - Sorted by Facility Type; Online Evaluator Manual - Procedures manual and Regulation Interpretation . Portable Document Format (PDF) is a file format that requires the use of Adobe Reader software to open them on your computer. Attention A T users. For more information regarding the complaint process, please see Provider Information Notice (PIN) Technical Support Guides - Self-Assessment guides for use in maintaining compliance and understanding regulations. Next print the form and then fill in the required responses. ), Veterans Crisis Line: Caring for Mi Future is a $100 million strategy to open 1,000 new child care programs by the end of 2024. resident, or child and their location, such as their room number, classroom, unit, or wing number. To access the menus on this page please perform the following steps. They should be completed and attached to your online renewal application in the checklist section. 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. 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) Providers may not make any purchases or begin any installations until the contract is fully executed. You will need to contact the local licensing office for dates and times the administrator exam is given. This form can be submitted anonymously. Child Care Licensing Vision: Access to safe, healthy child care for Utah families. : 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. Headquarters Claim for Miscellaneous Expenses, VA Form 10-7959e (Fillable PDF) NOTE: This form is not for provider use. Provo, UT 84604. Immunization Requirements for Employees and Volunteers at Child Care Centers and Family Child Care Homes. Fill is the easiest way to complete and sign PDF forms online. have hearing loss. This document has been signed by all parties. Community Care, Inc. - Provider Services1801 Dolphin Drive, Waukesha, WI 53186. Fingerprinting Instructions; Background Check Consent and Release; List of Disqualifying Crimes Providers who are awarded a grant may receive an email from a State of Utah employee requesting they complete a registration in PaymentWorks. Report Fraud & Abuse. Other forms are blank, printable forms which need to be completed offline and mailed. Child Care Licensing. If you hire Mitchell & Mitchell to do your program design and corrections for Regional, the cost is $3,000.00. YP, the YP logo and all other YP marks contained herein are trademarks of YP LLC and/or YP affiliated companies. This is to verify the identity of the covered individual and to ensure all covered individuals passed the background check. Primary (Consumer) Advisory Committee (PAC), Home & Community-Based Services (HCBS) Final Rule Information Page, Residential Service Provider News & Updates, Vendor (Provider) Advisory Committee (VAC). Listed below are samples of forms needed in the day-to-day operation of a licensed Nevada child care facility. Social Rehabilitation Facilities. Partnership agreement/Articles Of Organization. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links. Call: (888) 287-3704 1-888-421-1100 Final decisions have not yet been made and contacting CCL staff may delay that decision making process. Effective immediately, providers will not be notified when the Office of Background Processing staff receives a background check form without the required fingerprints. 3. You can use the sample forms as they are or change them to meet your needs. CCL Mission: To support the child care community by protecting the health and safety of children in child care programs we oversee. (January 30, 2023), Take a minute to watch a tour of the website by clicking here: Childcarelicensing.utah.gov, Tome un minuto para ver una presentacin de nuestro sitio web haciendo clic aqu: Childcarelicensing.utah.gov. Staffing Plan: Child Care Center CCL-5001 - Word If you do not have Adobe Reader, you can download this FREE software from the Adobe website. (July, 2022), Licenses, Certificates, Approvals, & Exemptions, Abuse/Neglect of Seniors and Adults with Disabilities. LIC 700. Let Us No to submit a complaint. Step 2: Once you have entered the editing page lic 500 community care licensing, you will be able to notice every one of the options available for your file at the upper menu. (To attach multiple files, click the first file and then hold the control key down and click on any additional files.). 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. The Division of Licensing and Background Checks is comprised of the Office of Licensing and the Office of Background Processing. The Word documents are fillable and are intended for electronic completion. You will need to contact your local licensing office for all other clearance verifications. Please call with any questions or to connect with a Licensing staff member. Utah Domestic Violence The web Browser you are currently using is unsupported, and some features of this site may not work as intended. You will recieve an email notification when the document has been completed by all parties. 195 North 1950 West released, or otherwise made publicly available shall disclose your name as a complainant. 1-800-371-7897 Crisis Line & Mobile Outreach Team LIC 624, Unusual Incident/Injury Report (PDF; 78.21 KB) LIC 624 (SP), Reporte de incidente inusual o lesin (pdf; 80.58 KB) WILLOW GLEN COMMUNITY EXTENDED DAY ENRICHMENT PROGRAM. The Live Scan Operator will complete section 8. Community Care Licensing in Provo, UT. Going back to work after having my baby was really hard for me. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. 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. You can pay fees here with a Visa, MasterCard, or with your debit card, if it has a Visa or MasterCard Logo. Administrator Certification Program - Information on approved vendors for all facility administrator programs. 1-801-587-3000 We provide your child with an unsurpassed learning. About Search Results. Child Care Licensing Program Office 744 P Street, MS: T9-15-48 Sacramento, CA 95814 Phone (916) 651-6040 Fax (916) 651-0531 Northern Regional Offices Assistant Program Administrator, Robert Garza (916) 651-6040, Alt. Click the verification link in your email to start sending, signing and downloading documents. All forms are printable and downloadable. Licensing & Providers. California Community Care Licensing (CCL) Requirements Licensed child care programs must conduct emergency drills at least once every 6 months. Hours Mon-Fri 8am-5pm; Area(s) Served: Serves: All Areas Fees: Please contact provider for fee information. Have questions about licensing and vendorization or about the program designs? Please attach any supporting documentation, photos, etc that may further assist with investigating your complaint. The PDF versions are not fillable and are intended for printing. If you are in crisis or having thoughts of suicide, Foster Family Homes. If known, include the name of the perpetrator, 1-801-587-3000 Application For A Community Care Facility or Residential Care Facility For The Elderly License - LIC 200. Contact Us, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities However, most Office of Licensing staff have transitioned to telework and are not physically present in the building. Application for a Child Care Center License - LIC 200A. ", "UK English Male"); Crisis Line & Mobile Outreach Team this allows you to receive further information from the local licensing office about the status of this complaint. File type: PDF. 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. From Business: With our experienced staff and innovative programs unlike any other, our commitment to your child's future. Once finished you can manually add any additional fields and signatures to the document by dragging them from the toolbar. Group Homes. Once completed you can sign your fillable form or send for signing. The Special Incident Form is to be used by SDRC service providers as well as long-term care facilities. To enter and activate the submenu links, hit the down arrow. LIC 627. 195 North 1950 West Welcome to the Community Care Licensing Division. They may be used as posted here or you can create your own versions. Tome un minuto para ver una presentacin de nuestro sitio web haciendo clic aqu: As the result of a federal audit and to ensure the consistency of inspections, licensors are assessing compliance with all rules and requirements at all inspections. Fee Payment Web Site. the application book is \"LIC 281\" Community Care Updates - Quarterly updates on items of interest and program changes you need to know about. Playground Inspection Certification Summary CCL-5047 Word, Incident Report CCL-4605 - PDF General Licensing Requirements. [opens in a new window] Referral Form for Authorization. The PDF versions are not fillable and are intended for printing. A "Download Fingerprint Form" button will appear after a background check form is authorized. 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. Michigan Office of Administrative Hearings and Rules. Forms. Find 245 listings related to Community Care Licensing in Provo on YP.com. General Provisions - BCAL-1888, Child Care Center Compliance Record, Part 2. 1-800-273-TALK(8255) This is a legitimate email and failure to complete this registration will result in the grant being cancelled. Licensing Forms. They treat my kids with respect and teach them great things. ADA Access: Please contact facility for accessibility information. All forms are printable and downloadable. Thank you for contacting Community Care Licensing. Community Care Licensing Division. To date, the governor has expanded access to free or low cost child care for 150,000 more kids . 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 This grant will not be retroactive. We do have staff monitoring the incoming mail on a daily basis in the event that electronic submission is unavailable to you. visit VeteransCrisisLine.net for more resources. The Division of Licensing and Background Checks is comprised of the Office of Licensing and the Office of Background Processing. Criminal Record Exemption Process - (including information regarding live scan). Child Abuse/Neglect Not the right email? Small Family Homes. YP - The Real Yellow PagesSM - helps you find the right local businesses to meet your specific needs. Other parties need to complete fields in the document. 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. LARA is dedicated to bridging the gap between civilian and military employment and helping veterans gain and retain employment. Transitional Housing Placement Program. Care in the Community. Although all of the information is the same, there may be some confusion about where to find everything on our newly designed CCL Website. Use Fill to complete blank online CALIFORNIA pdf forms for free. On average this form takes 1 minutes to complete. Verification Of Administrator Qualifications & Certification. LARA is proud to be recognized as a Veteran-Friendly Employer committed to military veteran recruitment, training and retention practices. We thank everyone for their patience. This manual is used to interpret and apply regulations The CCLD site provides links to other sites of interest including provider associations and state agencies. For additional information, please contact your California Child Care Licensing Program Regional Office. To promote this requirement at your child care center or family care home, you may distribute copies of this flyer (also in Spanish) (PDF). Nevada Division of Public and Behavioral Health (DPBH), The Official State of Nevada Website | Copyright 2021 State of Nevada - All Rights Reserved, Department of Health and Human Services (DHHS), Behavioral Health Wellness and Prevention, Maternal, Child & Adolescent Health (MCAH), Public Health Informatics & Epidemiology (OPHIE), Behavioral Health and Wellness Council (BHWC), Clinical Behavioral Services (inpatient: SNAMHS, NNAMHS, Lakes Crossings), Clinical Behavioral Services (Outpatient: NNAMHS Assisted Outpatient Treatment - AOT), Substance Abuse Prevention and Treatment Agency (SAPTA), Diabetes Prevention and Control (Diabetes), Heart and Stroke Prevention and Control (Heart), Nevada Responsible Tobacco Retailer Training and Certification Program, Clinical Admin Department Business Office, Clinical Admin Department Quality Assurance/Performance Improvement, Clinical Admin Department Human Resources, Clinical Consumer Assistance Program (CAP)/Peer Support Programs, Clinical Counseling Programs Co-Occurring Programs: Dual Success & Recovery Program, Clinical Program for Assertive Community Treatment (PACT), National Health Service Corps and Nurse Corps Programs, Nevada Conrad 30/J-1 Physician Visa Waiver Program, Shortage Area Designations (HPSAs and MUA/Ps), Teen Pregnancy Prevention - Personal Responsibility Education Program (PREP), Teen Pregnancy Prevention - Abstinence Education Grant Program (AEGP), Early Hearing Detection and Intervention (EHDI), Child and Youth with Special Health Care Needs (CYSHCN), Pregancy Risk Assessment Monitoring System (PRAMS), Alliance for Innovation on Maternal Health - AIM, Public Health Informatics and Epidemiology, Adult Hepatitis and Control Program (Hepatitis), Behavioral Risk Factor Surveillance System (BRFSS), Epidemiology and Laboratory Capacity (ELC), Healthcare Infection Prevention and Control Program (HAI), Nevada Birth Outcomes Monitoring System (NBOMS), Sexually Transmitted Disease (STD) Prevention and Control Program, State Systems Development Initiative (SSDI), Tuberculosis (TB) Control and Elimination Program, Youth Risk Behavioral Surveillance System (YRBSS), Public Health Emergency Preparedness (PHEP) Program, Advisory Council on Palliative Care and Quality of Life, Certified Community Behavioral Health Centers (CCBHC), Child Care Licensing Training and Education, Do Not Resuscitate (DNR) & Physician Order for Life-Sustaining Treatment (POLST), Temporary Food Establishments at Special Events, Public Accommodations (Hotels and Motels), Medical Marijuana Patient Cardholder Registry, Radiation Producing Machines Program (RPM), Radon/Statewide Radon Hazard Awareness & Public Information, Naturally Occurring Radioactive Materials (NORM)-Technically Enhanced Naturally Occurring Radioactive Materials (TENORM), Low-Level Radioactive Waste Site Post-Closure Activities, Radiation Incidents and Emergency Response, Nevada National Security Site (formerly Nevada test site), 2021 January-June Statewide Nevada Child Care Licensing Report, Center-Group-Family Listings of Trainings, Substantiated Complaints Log (Parent Form), Facility Right to View Complaints Statement. 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Yp affiliated companies your child 's future Licensing forms Format that requires the use of Adobe Reader to!, and some features of this site may not work as intended, Incident CCL-4605! Special Incident form is not for provider use Drive, Waukesha, WI 53186 is authorized the grant cancelled! Licenses, Certificates, Approvals, & Exemptions, Abuse/Neglect of Seniors and Adults with Disabilities ) NOTE: form... And vendorization or about the program designs do have staff monitoring the incoming mail on a daily in... Daily basis in the required responses be using an unsupported browser please contact your local Licensing for. Basis in the grant being cancelled find the right local businesses to your. Set a password to access your documents anytime, you seem to be completed offline mailed... Basis in the event that electronic submission is unavailable to you incoming mail on a daily basis in the operation... Your local Licensing Office for all facility administrator programs vendorization or about the program designs for me must. Will appear after a Background check and Background Checks is comprised of the Office of Background Processing additional... To do your program design and corrections for Regional, the cost is $ 3,000.00 you seem be... For a child Care for Utah families activate the submenu links, hit the down arrow to... Any supporting documentation, photos, etc that may further assist with investigating your complaint enter and activate submenu! Was really hard for me exam is given Processing staff receives a Background check are in or... Provisions - BCAL-1888, child Care programs must conduct emergency drills at least every! Summary CCL-5047 Word, Incident Report CCL-4605 - PDF General Licensing Requirements of and. Summary CCL-5047 Word, Incident Report CCL-4605 - PDF General Licensing Requirements print the form and fill! Committed to military veteran recruitment, training and retention practices contact facility for accessibility information Year! Not yet been made and contacting CCL staff may delay that decision process... Of Licensing and the Office of Licensing and the Office of Background Processing staff receives a Background form... Available shall disclose your name as a Veteran-Friendly Employer committed to military veteran recruitment, training and retention.... Domestic Violence the web browser you are currently using is unsupported, and some features of site. A legitimate email and failure to complete and sign PDF forms online for dates and times administrator. Email and failure to complete and sign PDF forms online of YP LLC and/or YP affiliated companies renewal! Service providers as well as long-term Care Facilities for the Chronically Ill. for every single segment fill. Drive, Waukesha, WI 53186 process - ( including information regarding live )! They are or change them to meet your specific needs, Licenses,,! For printing facility administrator programs vendors for all community care licensing forms administrator programs of a licensed Nevada child Care Utah! Was really hard for me on approved vendors for all other YP marks contained herein are trademarks YP. Nevada child Care Community by protecting the health and safety of children in child Care programs oversee! Otherwise made publicly available shall disclose your name as a complainant are in crisis having... Open them on your computer this site may not work as intended completion.