(559) 243-4588 LIC 624, Unusual Incident/Injury Report. Then mail the document to the appropriate Office of Child Care Regional Licensing Office. About Search Results. The Word documents are fillable and are intended for electronic completion. Partnership agreement/Articles Of Organization. Fingerprinting Instructions; Background Check Consent and Release; List of Disqualifying Crimes All program designs are in full compliance with HCBS final Rule. Fire Safety Provisions - BCAL-0722, Child Care Center Compliance Record, Part 4. We do not endorse and are not responsible for the content of the linked website. Utah Domestic Violence Please attach any supporting documentation, photos, etc that may further assist with investigating your complaint. Salt Lake City, Ut 84116, Child Care Licensing Contact Info 1-800-371-7897 Community Care Licensing in Provo, UT. Claim for Payment of Cost of Unauthorized Medical Services, VA Form 10-583 (Fillable PDF) Claim for Miscellaneous Expenses. This report provides a glimpse of child care numbers crossing jurisdictional lines by giving total number of licensed facilities, number of each type of facility licensed, number of substantiated and unsubstantiated complaints and more throughout Nevada. LIC 700. Send to someone else to fill in and sign. (To attach multiple files, click the first file and then hold the control key down and click on any additional files.). Our main office building is open to the public. Child Care Licensing Program Office 744 P Street, MS: T9-15-48 Sacramento, CA 95814 Phone (916) 651-6040 Fax (916) 651-0531 Northern Regional Offices Assistant Program Administrator, Robert Garza (916) 651-6040, Alt. the application book is \"LIC 281\" Community Care Updates - Quarterly updates on items of interest and program changes you need to know about. Salt Lake City, Ut 84116, DLBC Contact Info Website (801) 669-5370. This is to make the processes more efficient. This is a legitimate email and failure to complete this registration will result in the grant being cancelled. They should be completed and attached to your online renewal application in the checklist section. The Community Care Licensing (California) form is 1 page long and contains: Fill has a huge library of thousands of forms all set up to be filled in easily and signed. (November 10, 2022), The fingerprint form is now generated through the provider's Child Care Licensing Portal. Application for Child Care Plan Review (BCHS-FS-13), Child Care Center Notice of Arraignment or Conviction CCL-1486 - PDF, Child Care Center Notice of Arraignment or Conviction CCL-1486 - Word, Child Information Record - CCL-3731 Web Proected, Child Information Record - BCAL 3731-AR (Arabic), Documento de Informacin del Nio Estado de Michigan - BCAL-3731-SP, Written Information Packet Documentation CCL-4340 - PDF, Written Information Packet Documentation CCL-4340 - Word, Change of Use Space Request for School-Age Programs Located in Schools CCL-4342 - PDF, Change of Use Space Request for School-Age Programs Located in Schools CCL-4342 - Word, Lead Hazard Risk Assessment Summary CCL-4344 - PDF, Lead Hazard Risk Assessment Summary CCL-4344 - Word, No Change in Building Construction Declaration CCL-2129 - PDF, No Change in Building Construction Declaration CCL-2129 - Word, Infant/Toddler Primary Caregiver Documentation CCL-4557 - PDF, Infant/Toddler Primary Caregiver Documentation CCL-4557 - Word, Center Fire and Tornado Drill Record - CCL-4593 - PDF, Center Fire and Tornado Drill Record - CCL-4593 - Word, Staffing Plan: Child Care Center CCL-5001 - PDF IMPORTANT: You must have Adobe Reader version 6.0 or later installed on your computer to view the documents on this site. Click the verification link in your email to start sending, signing and downloading documents. Listed below are samples of logs neededin the ongoing operation of a licensed Nevada child care facility. Step 2: Once you have entered the editing page lic 500 community care licensing, you will be able to notice every one of the options available for your file at the upper menu. 1-800-897-LINK(5465), How to Submit Background Check Forms and Fingerprints, Background Check Requests From Other States. 1-855-323-DCFS(3237) Child Abuse/Neglect Headquarters Human Services License. Hours Mon-Fri 8am-5pm; Area(s) Served: Serves: All Areas Fees: Please contact provider for fee information. Cancel at any time. Effective immediately, providers will not be notified when the Office of Background Processing staff receives a background check form without the required fingerprints. (January 30, 2023), Take a minute to watch a tour of the website by clicking here: Childcarelicensing.utah.gov, Tome un minuto para ver una presentacin de nuestro sitio web haciendo clic aqu: Childcarelicensing.utah.gov. NOTE: Only use this form for one time release of information. Licensing & Providers. Salt Lake City, UT 84116. Select option 1 for Claims and Eligibility. Care in the Community. COMMUNITY CARE LICENSING DIVISION ADVOCACY AND TECHNICAL SUPPORT RESOURCE GUIDE MEDICATIONS FOR SENIOR CARE FACILITIES TSP 2016-03 (version 09/30/2016) PAGE 4 Incidental Medical and Dental Care Services (22 CCR 87465) Scenario: Description of Regulations: Best Practices: Medications required to be centrally stored, continued Practice "duck, cover, and hold" earthquake drills under tables or desks no less than four times per year. [opens in a new window] Referral Form for Authorization. Staffing Plan: Child Care Center CCL-5001 - Word : DIRECT DEPOSIT CALIFORNIA To (California), FACILITY SKETCH (Floor Plan) - Family Child Care (California), UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) (California), State of California Department of Insurance Live Scan (California), WG-012 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California), Retirement Allowance Estimate Request (California), ATTACHMENT TO PROOF OF ELECTRONIC SERVICE (PERSONS SERVED) (California), Form 2: FW-002 Request to Waive Additional Court (California), POS-050/EFS-050 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California), form to sign prior to submittal. Salt Lake City, UT 84116, Headquarters Going back to work after having my baby was really hard for me. Sexual Violence Crisis Line Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. Hit enter to expand a main menu option (Health, Benefits, etc). Child Abuse/Neglect 1. Please switch auto forms mode to off. 1. Listed below are samples of forms needed in the day-to-day operation of a licensed Nevada child care facility. [opens in a new window] IHPP Referral Form for Authorization. Application for a. For every single segment, fill out the content requested by the software. COVID-19 Information and Resources. We are pleased to announce Child Care Licensing is now part of the newly consolidated Department of Health and Human Services (DHHS). From Business: With our experienced staff and innovative programs unlike any other, our commitment to your child's future. resident, or child and their location, such as their room number, classroom, unit, or wing number. Social Rehabilitation Facilities. 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. . this allows you to receive further information from the local licensing office about the status of this complaint. National Suicide Prevention Lifeline Nevada Division of Public and Behavioral Health (DPBH), The Official State of Nevada Website | Copyright 2021 State of Nevada - All Rights Reserved, Department of Health and Human Services (DHHS), Behavioral Health Wellness and Prevention, Maternal, Child & Adolescent Health (MCAH), Public Health Informatics & Epidemiology (OPHIE), Behavioral Health and Wellness Council (BHWC), Clinical Behavioral Services (inpatient: SNAMHS, NNAMHS, Lakes Crossings), Clinical Behavioral Services (Outpatient: NNAMHS Assisted Outpatient Treatment - AOT), Substance Abuse Prevention and Treatment Agency (SAPTA), Diabetes Prevention and Control (Diabetes), Heart and Stroke Prevention and Control (Heart), Nevada Responsible Tobacco Retailer Training and Certification Program, Clinical Admin Department Business Office, Clinical Admin Department Quality Assurance/Performance Improvement, Clinical Admin Department Human Resources, Clinical Consumer Assistance Program (CAP)/Peer Support Programs, Clinical Counseling Programs Co-Occurring Programs: Dual Success & Recovery Program, Clinical Program for Assertive Community Treatment (PACT), National Health Service Corps and Nurse Corps Programs, Nevada Conrad 30/J-1 Physician Visa Waiver Program, Shortage Area Designations (HPSAs and MUA/Ps), Teen Pregnancy Prevention - Personal Responsibility Education Program (PREP), Teen Pregnancy Prevention - Abstinence Education Grant Program (AEGP), Early Hearing Detection and Intervention (EHDI), Child and Youth with Special Health Care Needs (CYSHCN), Pregancy Risk Assessment Monitoring System (PRAMS), Alliance for Innovation on Maternal Health - AIM, Public Health Informatics and Epidemiology, Adult Hepatitis and Control Program (Hepatitis), Behavioral Risk Factor Surveillance System (BRFSS), Epidemiology and Laboratory Capacity (ELC), Healthcare Infection Prevention and Control Program (HAI), Nevada Birth Outcomes Monitoring System (NBOMS), Sexually Transmitted Disease (STD) Prevention and Control Program, State Systems Development Initiative (SSDI), Tuberculosis (TB) Control and Elimination Program, Youth Risk Behavioral Surveillance System (YRBSS), Public Health Emergency Preparedness (PHEP) Program, Advisory Council on Palliative Care and Quality of Life, Certified Community Behavioral Health Centers (CCBHC), Child Care Licensing Training and Education, Do Not Resuscitate (DNR) & Physician Order for Life-Sustaining Treatment (POLST), Temporary Food Establishments at Special Events, Public Accommodations (Hotels and Motels), Medical Marijuana Patient Cardholder Registry, Radiation Producing Machines Program (RPM), Radon/Statewide Radon Hazard Awareness & Public Information, Naturally Occurring Radioactive Materials (NORM)-Technically Enhanced Naturally Occurring Radioactive Materials (TENORM), Low-Level Radioactive Waste Site Post-Closure Activities, Radiation Incidents and Emergency Response, Nevada National Security Site (formerly Nevada test site), 2021 January-June Statewide Nevada Child Care Licensing Report, Center-Group-Family Listings of Trainings, Substantiated Complaints Log (Parent Form), Facility Right to View Complaints Statement. The PDF versions are not fillable and are intended for printing. Crisis Line & Mobile Outreach Team Complete our forms to check eligibility, report incidents, or assessment worksheets, Our counselors and staff can help you with your requests or concerns. English. 195 North 1950 West 1-800-897-LINK(5465), Division of Licensing and Background Checks, Abuse/Neglect of Seniors and Adults with Disabilities. COMMUNITY CARE LICENSING DIVISION ADVOCACY AND TECHNICAL SUPPORT RESOURCE GUIDE MEDICATIONS FOR SENIOR CARE FACILITIES TSP 2016-03 (version 09/30/2016) PAGE 4 Incidental Medical and Dental Care Services (22 CCR 87465) Scenario: Description of Regulations: Best Practices: Medications required to be centrally stored, continued 2021 January-June Statewide Nevada Child Care Licensing Report; Forms - Background. This program design is separate and distinct from the CCLD program design. This manual is used to interpret and apply regulations The CCLD site provides links to other sites of interest including provider associations and state agencies. Dismiss, CDSS Vendor: ARF #2000079-735-2 | BRN | #CEP16081 | CNA NAC#7050 | GH#2000079-730-2 | NHA #CEP1619 | NASW #886756920 | RCFE #2000079-740-2 | STRTP #2000079-733-2 | RCFE ICTP #2000079-740-1, Admission Agreement For Residential Care Facilities For The Elderly, Admission Agreement Guide For Residential Facilities, Affidavit Regarding Client/Resident Cash Resources, Affidavit Regarding Liability Insurance For Family Child Care Home, Application for a Child Care Center License, Application For A Community Care Facility or Residential Care Facility For The Elderly License, Application For A Family Child Care Home License, Application Instructions for A Facility License, Centrally Stored Medication And Destruction Record, Certificate Of Approval (For Certified Family Homes), Child Abuse Central Index Check For State Licensed Facilities, Civil Penalty Assessment (Unlicensed Facility), Civil Penalty Ledger Payment, Reduction, Or Waiver Record, Client/Resident Personal Property And Valuables, Consent For Emergency Medical Treatment Child Care Centers Or Family Child Care Homes, Consent For Emergency Medical Treatment Childrens Residential Facilities, Consent For Emergency Medical Treatment Adult And Elderly Residential Facilities, Criminal Background Clearance Transfer Request, Criminal Record Statement Adoption Facilitator, Criminal Record Statement Long-Term Ombudsman Program, Current Children In Your Home Application For A Family Child Care Home License, Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities, Emergency Disaster Plan For Child Care Centers, Emergency Disaster Plan For Childrens Residential Facilities (Except Foster Family Homes), Emergency Disaster Plan For Family Child Care Homes, Emergency Disaster Plan For Residential Care Facilities For The Elderly, Financial Information Release And Verification, Forms/Records To Keep In Your Family Child Care Home, Foster Family Home Application Instructions, Gastrostomy Tube Care: Physicians Checklist (Child Care Facilities), Gastrostomy Tube Care Consent/Verification (Child Care Facilities), Health Screening Report Facility Personnel, Identification And Emergency Information Child Care Centers/Family Child Care Homes, License Application And Instructions For Child Care Centers, License Application And Instructions For Family Child Care Homes, Notice Of Operation In Violation Of Law Family Child Care Home, Notification Of Incomplete Foster Family Home Application, Notification Of Initial Application Denial, Orientation Meeting Family Child Care Home, Out-Of-State Child Abuse/Neglect Report Request, Out-Of-State Disclosure And Criminal Record Statement, Personal Rights Childrens Residential Facilities, Personal Rights Adult Residential Care Facilities, Personal Rights Residential Care Facilities for The Elderly (Publicly Operated), Personal Rights Residential Care Facilities for The Elderly (Privately Operated), Physicians Report For Community Care Facilities, Physicians Report For Residential Care Facilities For The Elderly (RCFE), Record Of Clients Cash Resources For Change Of Licensee, Record Of Clients/Residents Safeguarded Cash Resources, Records To Be Maintained At The Facility Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children, Records To Be Maintained At The Facility Adult Residential, Records To Be Maintained At The Facility Small Family Home And Foster Family Home, Records To Be Maintained At The Facility Residential Care Facility For The Elderly, Records To Be Maintained By The Facility Group Homes, Reference Request Long-Term Care Ombudsman Program, Release Of Client/Resident Medical Information, Reporting Requirements By Licensees To The State Department Of Social Services, Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders, Unusual Incident/Injury Report Family Child Care Home, Your Right To Make Decisions About Medical Treatment. 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