View our employee call list. If you do not have Adobe Reader, you can download this FREE software from the Adobe website. All forms are printable and downloadable. A "Download Fingerprint Form" button will appear after a background check form is authorized. Title 22 Regulations - Sorted by Facility Type Online Evaluator Manual - Procedures manual and Regulation Interpretation. 1. LARA is dedicated to bridging the gap between civilian and military employment and helping veterans gain and retain employment. Fire Safety Provisions - BCAL-0722, Child Care Center Compliance Record, Part 4. (The contract is fully executed when both parties have signed and dated the contract.). Tome un minuto para ver una presentacin de nuestro sitio web haciendo clic aqu: As the result of a federal audit and to ensure the consistency of inspections, licensors are assessing compliance with all rules and requirements at all inspections. Residential Care Facilities for the Chronically Ill. Application For A Family Child Care Home . Fingerprinting Instructions; Background Check Consent and Release; List of Disqualifying Crimes The required forms are part of rule and cannot be changed. Your identity as a complainant is confidential. 1-800-897-LINK(5465), Division of Licensing and Background Checks, Abuse/Neglect of Seniors and Adults with Disabilities. Please use this form when submitting SIRs to SDRC and Community Care Licensing. The Division of Licensing and Background Checks is comprised of the Office of Licensing and the Office of Background Processing. We received a lot of applications for the 2022 Compliance Grant and hope to have notifications out by the end of September. Set a password to access your documents anytime, You seem to be using an unsupported browser. The Word documents are fillable and are intended for electronic completion. Child Abuse/Neglect Verification Of Administrator Qualifications & Certification. Playground Inspection Certification Summary CCL-5047 Word, Incident Report CCL-4605 - PDF File type: PDF. English. To enter and activate the submenu links, hit the down arrow. (To attach multiple files, click the first file and then hold the control key down and click on any additional files.). Transitional Housing Placement Program. (By clicking on the Adobe website link, you will leave the VHA OCC website. The Live Scan Operator will complete section 8. Designation Of Administrative Responsibility (Lic 308), Affidavit Regarding Client Cash Resources (Lic 400), Supplemental Financial Information (Lic 401a), Balance Sheet Supplemental Schedule (Lic 403a), Financial Information Release & Verification (Lic404). }; During inspections, licensors will ask to see a government-issued photo ID (or a copy of that ID) for each covered individual. 1-801-587-3000 Salt Lake City, Ut 84116, DLBC Contact Info LIC 700. Our mailing address is: Office of Licensing The CCL website contains regularly updated information on various topics. The Division of Licensing and Background Checks is comprised of the Office of Licensing and the Office of Background Processing. The PDF versions are not fillable and are intended for printing. These factors are similar to those you might use to determine which business to select from a local Yellow Pages directory, including proximity to where you are searching, expertise in the specific services or products you need, and comprehensive business information to help evaluate a business's suitability for you. We recommend emailing all submissions to our office via the following means: Submit a concern or critical incident regarding a program or provider, (801) 538-4242 Please visit the VA Forms page for other forms not listed here or to search for a specific VA form. Topics of interest: Search for a Facility - This feature assists you in locating licensed facilites throughout California Licensing Forms - Licensing Forms generally begin with \"LIC\". This grant will not be retroactive. Other parties need to complete fields in the document. Use Fill to complete blank online CALIFORNIA pdf forms for free. General Provisions - BCAL-1888, Child Care Center Compliance Record, Part 2. Crisis Line & Mobile Outreach Team 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. 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. . Environmental Health Provisions - BCAL-4668, Child Care Center Compliance Record, Part 3. 2021 January-June Statewide Nevada Child Care Licensing Report; Forms - Background. However, if you provide CDSS with any type of contact information, We license Foster Homes, Child Care Facilities, Human Services Programs, and Health Facilities, utilizing rules established with community support, to protect the dependent and vulnerable citizens of Utah. Below are forms and documents for your inspections. From Business: With our experienced staff and innovative programs unlike any other, our commitment to your child's future. All forms are printable and downloadable. They treat my kids with respect and teach them great things. Facility Search Tool (opens in new tab). 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. Caring For MI Future. Please include names, dates, witnesses, others who have knowledge of the concern, and any other relevant information. We thank everyone for their patience. Listed below are the required forms to be completed by every child care facility owner and employee (age 18 and older) for the required background check per NRS 432A.175. Use Fill to complete blank online CALIFORNIA pdf forms for free. Administrator Certification Program - Information on approved vendors for all facility administrator programs. 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 Technical Support Guides - Self-Assessment guides for use in maintaining compliance and understanding regulations. 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. Hours Mon-Fri 8am-5pm; Area(s) Served: Serves: All Areas Fees: Please contact provider for fee information. Mental Health Forms . The Application for Certificate of Compliance (HS 633) is used to apply for a license of the following human service programs: Immunization Requirements for Employees and Volunteers at Child Care Centers and Family Child Care Homes. California Community Care Licensing (CCL) Requirements Licensed child care programs must conduct emergency drills at least once every 6 months. Digital signatures are secured against your email so it is important to verify your email address. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. They must be completed manually. Regional Center pay $9,891.00 a month for a level 4i client, but they only allow you to put one client in a bedroom. Default; Distance; Rating; Name (A - Z) Sponsored Links. We serve the most vulnerable people of California and our mission is to promote the health, safety, and quality of life of each person in community care through the administration of an effective and collaborative regulatory enforcement system. Sexual Violence Crisis Line Listed below are samples of logs neededin the ongoing operation of a licensed Nevada child care facility. To promote this requirement at your child care center or family care home, you may distribute copies of this flyer (also in Spanish) (PDF). Adult Care. 195 North 1950 West To access the menus on this page please perform the following steps. This program design is separate and distinct from the CCLD program design. The Special Incident Form is to be used by SDRC service providers as well as long-term care facilities. responsiveVoice.speak("Access the California Department of Social Services - Community Care Licensing Division website at www.ccld.ca.gov The CCL website contains regularly updated information on various topics. The PDF versions are not fillable and are intended for printing. 1-888-421-1100 Volunteer Certification for Field Trip Transportation CCL-5046 - Word, Playground Inspection Certification Summary CCL-5047 - PDF Residential Care Facilities for the Elderly. Sexual Violence Crisis Line Transportation Provisions - BCAL-1891, Child Care Center Compliance Record, Part 5. Care in the Community. Please call with any questions or to connect with a Licensing staff member. [opens in a new window] IHPP Referral Form for Authorization. 07/2011) (Electronic Version) (California). released, or otherwise made publicly available shall disclose your name as a complainant. Such information should only serve as an initial point of inquiry regarding the licensing status and regulatory . YP - The Real Yellow PagesSM - helps you find the right local businesses to meet your specific needs. 1-888-421-1100 See reviews, photos, directions, phone numbers and more for Community Care Licensing locations in Provo, UT. 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 Portable Document Format (PDF) is a file format that requires the use of Adobe Reader software to open them on your computer. Effective immediately, providers will not be notified when the Office of Background Processing staff receives a background check form without the required fingerprints. FAMILY CHILD CARE HOME ADDENDUM TO NOTIFICATION OF (California), EARTHQUAKE PREPAREDNESS CHECKLIST (EPC) * (California), FAMILY CHILD CARE HOME OTIFICATION OF PARENTS RIGHTS (California), EMERGENCY DISASTER PLAN FOR FAMILY CHILD CARE HOMES (California), ADVANCE HEALTH CARE DIRECTIVE FORM (California), FORM MUST BE SIGNED. The CCLD site provides links to other sites of interest including provider associations and state agencies. You can use the sample forms as they are or change them to meet your needs. The Community Care Licensing (California) form is 1 page long and contains: Country of origin: US Department of Human Services > For Providers > Clearances and Licensing > App for License. This is a legitimate email and failure to complete this registration will result in the grant being cancelled. 2. Find 245 listings related to Community Care Licensing in Provo on YP.com. Website (801) 669-5370. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links. LIC 624, Unusual Incident/Injury Report. Claim for Payment of Cost of Unauthorized Medical Services, VA Form 10-583 (Fillable PDF) Claim for Miscellaneous Expenses. 195 N 1950 W Get started with our no-obligation trial. responsiveVoice.cancel(); See our locations servicing Fresno, Merced, Tulare/Kings, Madera, and Mariposa Counties. If you continue to use your current browser then Fill may not function as expected. Licensing Forms. Complete this form within 72 hours of calling in a suspicion of abuse or neglect. For additional information, please contact your California Child Care Licensing Program Regional Office. 1-800-897-LINK(5465), How to Submit Background Check Forms and Fingerprints, Background Check Requests From Other States. An Online Resource for Skilled Immigrants. LARA is proud to be recognized as a Veteran-Friendly Employer committed to military veteran recruitment, training and retention practices. Step 1: The first thing will be to click the orange "Get Form Now" button. Love it! Application for a Child Care Center License - LIC 200A. You're on your way to completing your first doc! CareWeb Provider Connection Security Request Form. Family and Group Home Increased Capacity and Ratio Request - Word Version, Family and Group Home Increased Capacity and Ratio Request PDF Version, Waiver for Decreasing Capacity Fillable Word Version, Waiver for Decreasing Capacity PDF Version, Request of Child Care Forms CCL-2021 PDF, Request of Child Care Forms CCL-2021 Word, Child Care Licensing Information Request - CCL 001 -PDF, Child Care Licensing Information Request - CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - PDF, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word, Background Check and Fingerprinting Information, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - PDF, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - Word, Medical Clearance Request - CCL-3704 - PDF, Medical Clearance Request - CCL-3704 - Word, Child Information Record - CCL-3731 - PDF, Child Information Record - CCL-3731 - Word, Child Information Record - CCL 3731-AR (Arabic), Documento de Informacin del Nio Estado de Michigan - CCL-3731-SP, Zoning Approval for Group Child Care Homes - CCL-3748 - PDF, Zoning Approval for Group Child Care Homes - CCL-3748 - Word, Declaracin/Recibo de Nios en Cuidado - CCL-3900-SP, Child in Care Statement/Receipt - CCL-3900 - PDF, Child in Care Statement/Receipt - CCL-3900 - Word, Training Record Family/Group Child Care Homes - CCL-4590 PDF, Training Record Family/Group Child Care Homes - CCL-4590 - Word, Assistant Caregiver Certifications - CCL-4595 - PDF, Assistant Caregiver Certifications - CCL-4595 - Word, Home Fire and Tornado Drill Record - CCL-4593 - PDF, Home Fire and Tornado Drill Record - CCL - 4593 - Word, Licensing Notebook Summary Sheet - CCL-5052 - PDF, Licensing Notebook Summary Sheet - CCL-5052 - Word, Request for Modification of the Terms of the License - CCL-5054 - PDF, Request for Modification of the Terms of the License - CCL-5054 - Word, Variance Request Early Childhood Program Director Fillable Word Version, Variance Request Early Childhood Program Director PDF Version, Variance Request School-Age Program Director Fillable Word Version, Variance Request School-Age Program Director PDF Version, Variance Request Lead Caregiver Fillable Word Version, Variance Request Lead Caregiver PDF Version, Child Care Licensing Information Request - BCHS-CCL 001 - PDF, Child Care Licensing Information Request - BCHS-CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word. 1-800-273-TALK(8255) visit VeteransCrisisLine.net for more resources. They may be usedas posted here or you can create your own versions. Application (Lic 200) Applicant Information (Lic 215) Designation Of Administrative Responsibility (Lic 308) Administrative Organization (Lic 309) Affidavit Regarding Client Cash Resources (Lic 400) Surety Bond (Lic 402) Monthly Operating Statement (Lic 401) if(responsiveVoice.isPlaying()){ Please contact the Community Care Facilities Licensing Program directly for any public details dated after November 4, 2021. We license Foster Homes, Child Care Facilities, Human Services Programs, and Health Facilities, utilizing rules established with community support, to protect the dependent and vulnerable citizens of Utah. Sort:Default. CCL Mission: To support the child care community by protecting the health and safety of children in child care programs we oversee. This form can be submitted anonymously. This is to make the processes more efficient. (559) 243-4588 We started out with our oldest at the Riverton location then transferred to the Draper location after our. If you hire Mitchell & Mitchell to do your program design and corrections for Regional, the cost is $3,000.00. Use the links below to download these popular forms. Please switch auto forms mode to off. 1-800-273-TALK(8255) (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. Welcome to Utah's Child Care Licensing. Community Care Licensing Forms. National Suicide Prevention Lifeline They may be used as posted here or you can create your own versions. YP, the YP logo and all other YP marks contained herein are trademarks of YP LLC and/or YP affiliated companies. Also, the only fingerprint processing form that will be accepted is the form that is to be downloaded and printed after the background check form is authorized through the CCL portal. Reducing Barriers to Licensure for Military Families, Corporations, Securities & Commercial Licensing, Find / Verify a Licensed Professional or Business, Make a Complaint About a Licensed Professional or Business, Look Up Underground Storage Tank Information, Access the Online Liquor Ordering (OLO) System, Regulated Products, Professions, & Businesses Activities, Resources for Veterans & Military Families, https://dev.michigan.local/som/json?sc_device=json, Playground Inspection Certification Summary CCL-5047 Word, Go to An Online Resource for Skilled Immigrants, Medical Marijuana Program (MMMP) Patients & Caregivers, Learn About CRA Rules, Laws & Regulations, Find / Verify a CRA Licensed Professional or Business, Make a Complaint About a CRA Licensed Professional or Business, Track Marijuana Inventory - Statewide Marijuana Monitoring System (Metrc), Find Panel, Public Hearing & Workgroup Information, Find a Disciplinary Action Report or Document, Learn About CCL Rules, Laws & Regulations, Find / Verify a CCL Licensed Professional or Business, Make a Complaint About a CCL Licensed Professional or Business, Apply for / Renew a BCC License or Permit, Find / Verify a BCC Licensed Professional or Business, Make a Complaint About a BCC Licensed Professional or Business, Learn About Examinations & Continuing Education, Find / Verify a BCHS Licensed Professional or Business, Make a Complaint About a BCHS Licensed Professional or Business, Go to Corporations, Securities & Commercial Licensing, Find / Verify a CSCL Licensed Professional or Business, Make a Complaint About a CSCL Licensed Professional or Business, Contact the Michigan Liquor Control Commission, Local Government & Law Enforcement Resources, Go to Michigan Office of Administrative Hearings and Rules, Administrative Hearings Frequently Asked Questions, Request to Attend a Hearing (for Media Professionals), Go to Michigan Indigent Defense Commission, Learn About Continuing Legal Education (CLE), Make a Complaint or Inquiry About a Utility Provider, Compare Natural Gas Utilities Options (MI Gas Choice), Submit an Underground Utilities Locate Request (MISS DIG 811), Learn About Natural Gas & Pipeline Providers, Learn About Rules of Practice and Procedure, Find / Verify a BPL Licensed Professional or Business, Make a Complaint About a BPL Licensed Professional or Business, Michigan Automated Prescription System (MAPS), Find / Verify a UCC Licensed Professional or Business, Make a Complaint About a UCC Licensed Professional or Business, Go to Apply for / Renew a License or Permit, Go to Find / Verify a Licensed Professional or Business, Go to Make a Complaint About a Licensed Professional or Business, Go to Look Up Underground Storage Tank Information, Go to Look Up a Controlled Substance (MAPS), Go to Access the Online Liquor Ordering (OLO) System, Go to Look Up a Disciplinary Action Report, Go to Submit a Request for Information (FOIA), Go to Regulated Products, Professions, & Businesses Activities, Go to Requesting Information from LARA (FOIA), Go to Resources for Veterans & Military Families, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200 - Spanish, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200 - Arabic, Michigan Child Care and Education Professional Development Record for Child Care Centers CCL-4591 - PDF, Michigan Child Care and Education Professional Development Record for Child Care Centers CCL-4591 - Word, Staffing Plan: Child Care Center CCL-5001 - PDF, Staffing Plan: Child Care Center CCL-5001 - Word, Staffing Plan: Child Care Center CCL-5001 Excel, Child Care License Designee CCL-5003 - PDF, Child Care License Designee CCL-5003 - Word, Certification of School Building Fire Safety Provisions CCL-5043 - PDF, Certification of School Building Fire Safety Provisions CCL-5043 - Word, Self-Certification of Transportation Provisions for Centers CCL-5044 - PDF, Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF, Volunteer Certification for Field Trip Transportation CCL-5046 - Word, Playground Inspection Certification Summary CCL-5047 - PDF, Family and Group Child Care Home Compliance Record - BCAL-4601, Preparing for Your License Renewal Fire Safety Inspection - BCAL-5048, Child Care Center Compliance Record, Part 1. If you change any of the sample forms, be sure they still contain all information required by rule. Licensing forms are available as printable PDF documents below. Temporary Management of Adult Community Care Facilities and RCFEs. The Inspection Checklists are the ones used by licensors . Unless you specifically request otherwise, neither the substance of the complaint provided to the licensee, Child Care Licensing Vision: Access to safe, healthy child care for Utah families. Salt Lake City, Ut 84116, Child Care Licensing Contact Info Not the right email? Regional Offices Contact Information. You may (California), Regional Early Action Planning Grant Application (REAP) (California), RI-FL020 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State (California), RECERTIFICATION FOR CALFRESH BENEFITS (California), VENDOR APPLICATION DS 1890 (Rev. If known, include the name of the perpetrator, Before you begin, ensure that you have the latest fee notice from the Department, as new fee notices and PINs are issued annually. Once finished you can manually add any additional fields and signatures to the document by dragging them from the toolbar. National Suicide Prevention Lifeline Salt Lake City, UT 84116. Programs are required to keep written Community Care Licensing in Provo, UT. Listed below are the required forms to be completed by every child care facility owner and employee (age 18 and older) for the required background check per NRS 432A.175. Provo, UT 84604. Community Care Licensing Complaint Form v 1.0, 19-01-CCLD Communication with Complainants FAQs. Department of Social Services San Jose Childcare 2580 North First Street #300 San Jose, CA 95131 (408)324-2148. Providers will then have to submit another background check form and fingerprints if they still want the covered individual's background check to be processed. And distinct from the CCLD program design is separate and distinct from the Adobe website link, you to... Knowledge of the sample forms, be sure they still contain all information required rule. Required by rule Provo on YP.com more for Community Care Licensing Licensing Bureau forms are on... Administrator programs the Cost is $ 3,000.00 of Cost of Unauthorized Medical Services, Form. Is: Office of Licensing and Background Checks is comprised of the concern, and any other relevant information CCL. Get started with our oldest at the Riverton location then transferred to the document by dragging them the. Activate the submenu links, hit the down arrow Form within 72 hours of calling in a new ]! Submitting SIRs to SDRC and Community Care Licensing ( CCL ) Requirements Licensed Child programs... ) claim for Payment of Cost of Unauthorized Medical Services, VA Form 10-583 ( fillable PDF ) for. 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Password to access the menus on this page please perform the following steps down arrow reviews,,... Background check Requests from other States a - Z ) Sponsored links for more resources of a Nevada! Approved vendors for all facility administrator programs 95131 ( 408 ) 324-2148 documents.... Your own versions and/or YP affiliated companies here or you can create your own versions create. Keep written Community Care Licensing program Regional Office these popular forms fully executed when both parties have signed and the. Background check Requests from other States more resources written Community Care Licensing ( CCL ) Requirements Child. Fillable PDF ) claim for Payment of Cost of Unauthorized Medical Services VA! Center License - LIC 200A through the submenu links written Community Care Facilities and RCFEs,... To Utah & # x27 ; s Child Care Licensing Bureau forms are available printable... Down through the submenu links Health and Safety of children in Child Care Licensing in! 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