From Business: With our experienced staff and innovative programs unlike any other, our commitment to your child's future. Welcome to Utah's Child Care Licensing. Below are forms and documents for your inspections. Payment/Insurance Accepted: Please contact provider for accepted forms of payment. Welcome to the Community Care Licensing Division. This program design is separate and distinct from the CCLD program design. California Community Care Licensing (CCL) Requirements Licensed child care programs must conduct emergency drills at least once every 6 months. All forms are printable and downloadable. Please call with any questions or to connect with a Licensing staff member. To promote this requirement at your child care center or family care home, you may distribute copies of this flyer (also in Spanish) (PDF). Application for a Child Care Center License - LIC 200A. Email: dhslicensing@utah.gov, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities Our main office building is open to the public. To date, the governor has expanded access to free or low cost child care for 150,000 more kids . 1-888-421-1100 Once completed you can sign your fillable form or send for signing. Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF Hours Mon-Fri 8am-5pm; Area(s) Served: Serves: All Areas Fees: Please contact provider for fee information. 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 Let Us No to submit a complaint. All other marks contained herein are the property of their respective owners. the application book is "LIC 281" Community Care Updates - Quarterly updates on items of interest and program changes you need to know about. Verification Of Administrator Qualifications & Certification. Title 22 Regulations - Sorted by Facility Type Online Evaluator Manual - Procedures manual and Regulation Interpretation. Crisis Line & Mobile Outreach Team responsiveVoice.speak("Access the California Department of Social Services - Community Care Licensing Division website at www.ccld.ca.gov The CCL website contains regularly updated information on various topics. Title 22 Regulations - Sorted by Facility Type; Online Evaluator Manual - Procedures manual and Regulation Interpretation . Swimming Provisions - BCAL-1890, Child Care Home Record Requirements - BCAL-5040, Child Care Center Record Requirements - BCAL-5041. Our analysts can investigate your complaint more thoroughly when sufficient details are provided. To enter and activate the submenu links, hit the down arrow. Caring for Mi Future is a $100 million strategy to open 1,000 new child care programs by the end of 2024. Family and Group Home Increased Capacity and Ratio Request - Word Version, Family and Group Home Increased Capacity and Ratio Request PDF Version, Waiver for Decreasing Capacity Fillable Word Version, Waiver for Decreasing Capacity PDF Version, Request of Child Care Forms CCL-2021 PDF, Request of Child Care Forms CCL-2021 Word, Child Care Licensing Information Request - CCL 001 -PDF, Child Care Licensing Information Request - CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - PDF, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word, Background Check and Fingerprinting Information, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - PDF, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - Word, Medical Clearance Request - CCL-3704 - PDF, Medical Clearance Request - CCL-3704 - Word, Child Information Record - CCL-3731 - PDF, Child Information Record - CCL-3731 - Word, Child Information Record - CCL 3731-AR (Arabic), Documento de Informacin del Nio Estado de Michigan - CCL-3731-SP, Zoning Approval for Group Child Care Homes - CCL-3748 - PDF, Zoning Approval for Group Child Care Homes - CCL-3748 - Word, Declaracin/Recibo de Nios en Cuidado - CCL-3900-SP, Child in Care Statement/Receipt - CCL-3900 - PDF, Child in Care Statement/Receipt - CCL-3900 - Word, Training Record Family/Group Child Care Homes - CCL-4590 PDF, Training Record Family/Group Child Care Homes - CCL-4590 - Word, Assistant Caregiver Certifications - CCL-4595 - PDF, Assistant Caregiver Certifications - CCL-4595 - Word, Home Fire and Tornado Drill Record - CCL-4593 - PDF, Home Fire and Tornado Drill Record - CCL - 4593 - Word, Licensing Notebook Summary Sheet - CCL-5052 - PDF, Licensing Notebook Summary Sheet - CCL-5052 - Word, Request for Modification of the Terms of the License - CCL-5054 - PDF, Request for Modification of the Terms of the License - CCL-5054 - Word, Variance Request Early Childhood Program Director Fillable Word Version, Variance Request Early Childhood Program Director PDF Version, Variance Request School-Age Program Director Fillable Word Version, Variance Request School-Age Program Director PDF Version, Variance Request Lead Caregiver Fillable Word Version, Variance Request Lead Caregiver PDF Version, Child Care Licensing Information Request - BCHS-CCL 001 - PDF, Child Care Licensing Information Request - BCHS-CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word. 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. Sexual Violence Crisis Line Community Care Licensing Complaint Form v 1.0, 19-01-CCLD Communication with Complainants FAQs. Michigan Office of Administrative Hearings and Rules. CCLD's program design consists of the following elements: PART A / licensing Forms. Licensing Forms. These forms are required for your renewal application. } Love it! 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. The CCL website contains regularly updated information on various topics. 2021 January-June Statewide Nevada Child Care Licensing Report; Forms - Background. (By clicking on the Adobe website link, you will leave the VHA OCC website. The Community Care Licensing Division of the California Department of Social Services has provided this document search application to provide the public with access to information regarding facilities licensed by the Division. (November 10, 2022), The fingerprint form is now generated through the provider's Child Care Licensing Portal. Community Care Licensing in Provo, UT. [opens in a new window] Referral Form for Clinical Trials. Fill has a huge library of thousands of forms all set up to be filled in easily and signed. You have successfully completed this document. Great with the children, beautiful and clean home, and home cooked meals! We are pleased to announce Child Care Licensing is now part of the newly consolidated Department of Health and Human Services (DHHS). Contact us and well get back to you soon. 1-800-897-LINK(5465), Division of Licensing and Background Checks, Abuse/Neglect of Seniors and Adults with Disabilities. Completing the transition to our new database is a priority. A "Download Fingerprint Form" button will appear after a background check form is authorized. 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. However, if you provide CDSS with any type of contact information, have hearing loss. Practice "duck, cover, and hold" earthquake drills under tables or desks no less than four times per year. I looked for a long time for a daycare where I knew my son would be loved and cared, Im super satisfied with this childcare! }; To access the menus on this page please perform the following steps. Home > School Year Summer Fun FORMS Newsletter Gallery Community Care Licensing Forms . Fillable Portable Document Formats can be completed online, edited, saved and printed. GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING Instructions for the LIC 9163 1. . Applicant Fingerprint Follow-Up Request - LIC 107. Community Care, Inc. - Provider Services1801 Dolphin Drive, Waukesha, WI 53186. Please include names, dates, witnesses, others who have knowledge of the concern, and any other relevant information. 1-801-587-3000 Providers who are awarded a grant may receive an email from a State of Utah employee requesting they complete a registration in PaymentWorks. Final decisions have not yet been made and contacting CCL staff may delay that decision making process. (559) 243-4588 The required forms are part of rule and cannot be changed. Mitchell & Mitchell - Community Care Program Design Consultants. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. Digital signatures are secured against your email so it is important to verify your email address. Contact Us, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities Multi-Agency State Office Building Please switch auto forms mode to off. [opens in a new window] IHPP Referral Form for Authorization. visit VeteransCrisisLine.net for more resources. Care in the Community. Transitional Housing Placement Program. Transportation Provisions - BCAL-1891, Child Care Center Compliance Record, Part 5. Use Fill to complete blank online CALIFORNIA pdf forms for free. If you do not have or did not receive a current . The PDF versions are not fillable and are intended for printing. Program Updates - these updates provide valuable information for new regulations, policy changes, and useful information for providers. Complete our forms to check eligibility, report incidents, or assessment worksheets, Our counselors and staff can help you with your requests or concerns. From Business: Orem KinderCare located at 765 E 1200 S in Orem, UT is designed with your child's fun, health, safety, and childhood education in mind. Crisis Line & Mobile Outreach Team 195 N 1950 W You can use the sample forms as they are or change them to meet your needs. released, or otherwise made publicly available shall disclose your name as a complainant. CCL Mission: To support the child care community by protecting the health and safety of children in child care programs we oversee. Click the verification link in your email to start sending, signing and downloading documents. Regional Center pay $9,891.00 a month for a level 4i client, but they only allow you to put one client in a bedroom. Set a password to access your documents anytime, You seem to be using an unsupported browser. LIC 700. Licensing forms are available as printable PDF documents below. | 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. 22 Regulations - Sorted by Facility Type Online Evaluator Manual - Procedures Manual and Interpretation! 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