Content Overview
Guide to Writing Lic 500
Filling out the Lic 500 form is an important step in maintaining accurate records for your facility's personnel. This form helps ensure compliance with regulations and provides necessary information about staff members. Follow these steps to complete the form correctly.
- Begin by entering the name of the facility at the top of the form.
- Next, specify the facility type and facility number.
- Fill in the prepared by section with your name and the date.
- In section A, list all staff members subject to criminal background check requirements.
- For each staff member, provide their name, job title, and days and hours on duty.
- Indicate the employment dates for each staff member in the specified format.
- In section B, identify staff exempt from criminal background check requirements.
- Again, for each exempt staff member, include their name, job title, and employment dates.
- Have the licensee or designated representative sign to verify the exemption status.
- Finally, write the date next to the signature.
Once you have completed the form, send the original to the licensing agency. Keep a copy for your facility's records. This ensures that you have the necessary documentation on hand for future reference.
Document Breakdown
| Fact Name | Details |
|---|---|
| Purpose | The Lic 500 form is used to maintain a current roster of facility personnel and other adults residing in the facility. |
| Governing Law | 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 as required by California law. |
| Exemptions | Certain individuals may be exempt from background checks under specified sections of the Health and Safety Code. |
| Submission Requirements | The original form must be sent to the licensing agency, and a copy should be retained in the facility file. |
| Staff Information | The form collects detailed information about staff, including job titles, days, and hours on duty. |
| Updates | Facilities must report any changes in personnel to the licensing agency as required by regulations. |
| Version Information | The current version of the Lic 500 form is dated November 2003. |
FAQ
What is the purpose of the Lic 500 form?
The Lic 500 form is designed to maintain an up-to-date roster of all personnel and adults residing in a facility. This includes backup staff, volunteers, and the licensee or administrator. It ensures that the facility complies with regulations by tracking personnel who are subject to criminal background checks and reporting any changes to the licensing agency. The original form must be sent to the licensing agency, while a copy should be kept on file at the facility.
Who needs to be listed on the Lic 500 form?
All staff members who work in the facility must be listed on the Lic 500 form. This includes:
- Licensee or Administrator
- Staff subject to criminal background checks
- Exempt staff, if applicable
- Volunteers and backup persons
Additionally, specialized staff, such as social workers, should include their license or certificate number if applicable. It's crucial to keep this information current to ensure compliance with state regulations.
What are the requirements for staff subject to criminal background checks?
Staff members who fall under specific sections of the Health and Safety Code are required to undergo a criminal background check. This includes anyone who will be employed, residing, or initially present at the facility. A California background clearance or a criminal record exemption must be obtained before they can start working. This process is essential for ensuring the safety and well-being of all individuals in the facility.
What should I do if there are changes in personnel?
If there are any changes in personnel, it is important to report these changes to the licensing agency as required by regulations. This includes adding new staff, removing staff, or any changes in job titles or duties. Keeping the Lic 500 form updated is vital for compliance and helps maintain a safe environment for everyone in the facility.
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Lic 500 Example
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
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.
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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
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