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Licensing

LICENSING FORMS – FAMILY CHILD CARE HOMES

PUB 394 – Notification of Parents’ Rights

LIC 9148 – Earthquake Preparedness

LIC 610A – Emergency Disaster Plan

LIC 999A – Facility Floor Plan

LIC 9040 – Facility Roster

RECORDS TO MAKE AVAILABLE DURING INSPECTION

  • Current pediatric first aid certification issued by the American Heart Association, American Red Cross or by approved Emergency Medical Services Authority (EMSA) vendor
  • Proof of immunization of measles, pertussis, influenza and COVID 19 (or documentation of exemption)
  • TB Clearance or risk assessment (documentation from doctor or pharmacy)
  • Fingerprint Clearance for all adults in the FCC home (licensee, residents over 18 and staff)
  • Liability Insurance Certificate

LIC - 508 – Criminal Record Statement

LIC - 9108 Statement Acknowledging Requirement to report child abuse

LIC – 9052 Employee Rights

Mandated Reporter Training Certificate or (Language Waiver)

CHILDREN'S RECORDS

Parent/Guardian Approval to give Medicine (create your own)

LIC - 282 Affidavit Regarding Liability Insurance (if licensee has no liability insurance/bond)

LIC 700 – Identification and Emergency Information (permissible to use your own form containing the same information)

LIC 627 – Consent for Medical Treatment

LIC 995A – Notification of Parents’ Rights

LIC 9227 – Infant Individual Sleep Plan (available in Spanish/Korean/Chinese/Vietnamese)

LIC 9224 – Acknowledgement Receipt of Licensing Reports (if applicable)

IDENTIFY LOCATION

  • Locked and Secure Medication stored at facility (includes medication for permissible medical services, if applicable)
  • Functioning Carbon Monoxide Detector, Smoke Alarm(s) Fire Extinguisher
  • Most often used licensing forms related to family childcare (not required unless applicable)

Family Child Care Licensing Application and Instructions

LIC 279 – Application for Family Child Care License (required if making changes to license)

LIC 9280 – Pre-licensing Checklist

LIC 9121 – Facility Visit Checklist (what licensing program analyst LPA is looking for)

LIC 857 – Children’s Record Review

LIC 9151 – Landlord Notification of Family Child Care (not consent)

LIC 624B – Unusual Incident Report form

LIC 9149 – Landlord Consent for Additional Children in Care (more than 6)

LIC 9163 – Request for LIVESAN Service

LICENSING RESOURCES (TRANSLATIONS AVAILABLE ON THE PAGE)

Family Child Care Licensing Regulations

Community Care Licensing Resource Guides

Community Care Licensing Health & Safety Resources

Safe Sleep Regulations

Licensing Forms Translated

Safe Sleep Resource Page

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