Lic 809 2026

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The document is a Facility Evaluation Report from the California Department of Social Services, detailing the licensing visit to a facility. It outlines the types of deficiencies (Type A and Type B) that may be cited during inspections, the process for addressing these deficiencies through Plans of Correction (POCs), and the potential civil penalties for non-compliance. The report emphasizes the rights of licensees to appeal decisions and provides guidelines for correction notifications and agency reviews.

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Click ‘Get Form’ to open the lic 809 in the editor.
Begin by entering the facility name, director, and facility number in the designated fields. Ensure accuracy as this information is crucial for identification.
Fill in the address and telephone number of the facility. This helps maintain clear communication with licensing authorities.
Select the type of visit from options such as Office, Prelicensing, Management Annual, or Follow-up. Mark any applicable deficiencies on the left side of the form.
Document any civil penalties if applicable. Indicate whether a penalty was assessed or cleared and provide comments regarding deficiencies.
Complete the Plan of Corrections (POCs) section by detailing specific actions to address cited deficiencies. Be thorough to avoid misunderstandings.
Finally, ensure all signatures are obtained where required, including that of the licensing evaluator and facility representative before saving your document.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (210 Votes)
2004	4.1 Satisfied (35 Votes)

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What is the lic 508 form?

CRIMINAL RECORD STATEMENT OUT-OF-STATE DISCLOSURE. LIC 508 (7/21) Page 1 of 5 State law requires that persons associated with licensed care facilities, Home Care Aide Registry or TrustLine Registry applicants be fingerprinted and disclose any conviction.

What is a LIC 198B?

Additional child abuse/neglect check for persons who have lived out of state in the last five years. Complete one form for each prospective licensed or certified foster parent and any person over the age of 18 residing in their household. LIC 198B (3/11)

What is the California 7 year rule?

California prohibits CRAs from reporting convictions older than seven years under Cal. Civ. Code 1786.18(a)(7). This law also prohibits CRAs from reporting arrests not leading to convictions even if they occurred within the last seven years, but pending cases can be reported.

What is lic 500?

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.

What is a LIC 503?

The LIC 503 is required by the California Department of Social Services as part of the application process to work in a Community Care facility. It is used during the hiring process to verify the health of the applicant. It requires completion and signature by a physician.

facility evaluation form pdf

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What is LIC 610?

EMERGENCY DISASTER PLAN FOR CHILD CARE CENTERS. Post a copy in a prominent location in facility, near telephone. Licensee is responsible for updating information as required.