Ca form 5050-2025

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The document is a form from the California Department of Health Care Services for collecting staffing data at healthcare facilities. It requires information on staff qualifications, including licensing and certification status, training dates for CPR and First Aid, and details about counselors. The form emphasizes that at least 30% of staff providing counseling services must be licensed or certified.

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Click ‘Get Form’ to open the CA Form 5050 in the editor.
Begin by entering the 'Facility Name' at the top of the form. Ensure this is accurate as it identifies your facility.
In the 'Employee Information' section, list each staff member's name, title, and scheduled hours per week. For volunteers, place a 'V' after their names.
Complete the certification details for each employee. Indicate if they are registered, certified, or licensed by selecting 'Yes', 'No', or 'N/A'.
Fill in the dates for CPR and First Aid training under each staff member’s information. This is crucial for compliance with licensing requirements.
For counselors, provide their certification/registration number along with effective and expiration dates of their licensure or registration.

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Versions	Form popularity	Fillable & printable
2015	4.9 Satisfied (482 Votes)
2013	4.1 Satisfied (67 Votes)

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