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PROGRAMS (Group Home)

The forms below are requirements by Community Care Licensing for a Group Home Facility.  They are grouped based on Administration, Consumer, and Staff records needed to be sustained by a facility.

Administrative Records

LIC308-Designation of Facility Respo
LIC309-Administrative Organization
LIC400-Client Cash Resources
LIC402-Surety Bond
LIC500-Personnel Report
LIC610C-Diaster Plan
LIC9020-Roster of Facility Clients
LIC9106-Plan of Operation Group Home
LIC9165-Board of Directors Statement
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Child Records

LIC405-Record of Client Safeguarded
LIC601-Identification and Emergency
LIC602-Physician Report
LIC603-Preplacement Appraisal Inform
LIC604-Current Admission Agreement w
LIC605A-Release of Client Medical In
LIC613B-Personal Rights
LIC621-Client Personal Property and
LIC622-Centrally Stored Medication a
LIC624-Unusual Incident Injury Repor
LIC624A-Death Report
LIC625-Appraisal Needs and Services
LIC627B-Consent for Emergency Medica
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Records to be Maintained at the Facility

LIC311B-Records to be Maintained at
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Personal Records

LIC198A-Child Abuse Central Index Ch
LIC501-Personnel Record
LIC503-Health Screening Report
LIC508-Criminal Record Statment
LIC9052-Notice of Employee Rights
LIC9108-Statement Acknowledging Requ
LIC9163-Request for Live Scan
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