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I declare under penalty of perjury under the laws of the State of California that I have read and understand the information contained in this affidavit and that my responses and any accompanying attachments are true and correct. Signature Date If the person discloses a criminal conviction review the person s statement and discuss it with your Licensing Program Analyst LPA. Maintain this form in your facility/organization personnel file and send a copy to your LPA. PRIVACY STATEMENT Pursuant to ...

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What is an LIC 508?

CRIMINAL RECOR STATEMENT State law requires that persons associated with licensed facilities or Home Care Aide Registry applicants be fingerprinted and disclose any conviction. A conviction is any plea of guilty or nolo contendere (no contest) or a verdict of guilty.

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.