INSTRUCTIONS: PERSONNEL REPORT
STATE OF CALIFORNIA -- HEALTH AND HUMAN SERVICES AGENCY
PERSONNEL REPORT
NAME OF FACILITY PREPARED BY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
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. Show license/certificate number if applicable for specialized staff [e.g., Social Worker and other consultant(s)]. Show coverage for twenty-four hour supervision in residential facilities. Report any changes in personnel to the licensing agency as required by regulations. Send original to Licensing Agency and retain copy in facility file.
FACILITY TYPE
FACILITY NUMBER
DATE
A. STAFF SUBJECT TO CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following staff members are subject to a criminal background check pursuant to Sections 1522, 1568.09, 1569.17 and 1596.871 of the Health and Safety Code. A California background clearance or a criminal record exemption shall be obtained prior to employment, residence or initial presence in the facility.
NAME
Licensee/Administrator
DATE EMPL'D
JOB TITLE
SPECIFY DAYS AND HOURS ON DUTY
DAYS FROM
TO
SPECIFY DAYS AND HOURS ON DUTY
DAYS FROM
TO
SPECIFY DAYS AND HOURS ON DUTY
DAYS FROM
TO
LIC 500 (11/03) (PUBLIC)
Page 1 of 2
B. STAFF EXEMPT FROM CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following are believed exempt from criminal background check requirements pursuant to Sections 1522, 1568.09, 1569.17 and 1596.871 of the Health and Safety Code. The licensee or designated representative shall sign below to verify that he or she believes the indicated persons are exempt from criminal background check requirements pursuant to statute.
Signature ________________________________________________________________________________ Date __________________
NAME
DATE EMPL'D
JOB TITLE
SPECIFY DAYS AND HOURS ON DUTY
DAYS FROM
TO
SPECIFY DAYS AND HOURS ON DUTY
DAYS FROM
TO
SPECIFY DAYS AND HOURS ON DUTY
DAYS FROM
TO
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