2017 Notice Of Form Change

  • 17-091
    NA 835 (10/17) - Notice of Action - Child Care Discontinuance
  • 17-090
    SOC 809 (10/16) - Cash Assistance Program For Immigrants (CAPI) Indigence Exception Statement
  • 17-089
    SOC 2257 (3/16) - In-Home Supportive Services Program Notice To Provider Of First/Second Violation For Exceeding Workweek And/Or Travel Time Limits
    SOC 2257A (3/16) - In-Home Supportive Services Program Notice To Recipient Of Provider’s First/Second Violation For Exceeding Workweek And/Or Travel Time Limits
    SOC 2257B (3/16) - In-Home Supportive Services Program Notice To Provider Of Second Violation No Record Of Completion Of Review Of Instructional Materials
    SOC 2257C (3/16) - In-Home Supportive Services Program Notice To Provider Of Second Violation For Exceeding Workweek And/Or Travel Time Limits
    SOC 2258 (3/16) - In-Home Supportive Services Program Notice To Provider Of Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits
    SOC 2258A (3/16) - In-Home Supportive Services Program Notice To Recipient Of Provider’s Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits
    SOC 2259 (3/16) - In-Home Supportive Services Program Notice To Provider Of Fourth Violation (One-Year Period Of Ineligibility) For Exceeding Workweek And/Or Travel Time Limits
    SOC 2259A (3/16) - In-Home Supportive Services Program Notice To Recipient Of Provider’s Fourth Violation (One-Year Period Of Ineligibility) For Exceeding Workweek And/Or Travel Time Limits
  • 17-088
    CCP 9 (8/17) - Child Care Program (CCP) 9 Request For Policy Interpretation
  • 17-087
    SOC 2301 (4/17) - In-Home Supportive Services (IHSS) Or Waiver Personal Care Services (WPCS) Recipient Confirmation Of Enrollment In Electronic Timesheet
  • 17-086
    CF 11 (8/17) ENG/SP - Notice To All CalFresh Recipients Important - Please Read
  • 17-085
    CW 101 (7/17) - CalWORKs Immunization Rules
  • 17-084
    LIC 421FC (7/17) - Civil Penalty Assessment – Failure To Correct And Repeat Violations
  • 17-083
    LIC 421BG (6/17) - Civil Penalty Assessment – Caregiver Background Check
  • 17-082
    LIC 421IM (7/17) - Civil Penalty Assessment – Immediate $500 And Repeat Violations
  • 17-081
    RFA 00 (8/17) - Conversion to Resource Family: Release of Information
  • 17-080
    PUB 271 (2/17) - Never Shake a Baby Brochure (Black & White)
  • 17-079
    LIC 508D (8/17) - Out-Of-State Disclosure And Criminal Record Statement
  • 17-078
    LIC 198B (7/17) - Out-Of-State Child Abuse/Neglect Report
  • 17-077
    LIC 05A (7/17) - Resource Family Approval Certificate
  • 17-076
    LIC 03 (6/17) - Resource Family Home Health And Safety Assessment Checklist Document For Agency Use Only
  • 17-075
    RFA 812 (6/17) - Detail Supportive Information
  • 17-074
    RFA 03 (6/17) - Resource Family Home Health and Safety Assessment Checklist
  • 17-073
    CF 377.2B (6/17) - CalFresh Notice Of Expiration Of Certification For Households With Only Elderly And/Or Disabled Members
    CF 377.2C (6/17) - CalFresh Notice Of Expiration Of Certification For Households With Only Elderly And/Or Disabled Member
    CF 377.2D (6/17) - CalFresh Notice Of Status Change For Households With Only Elderly And/Or Disabled Members
  • 17-072
    SOC 876 (5/17) - In-Home Supportive Services (IHSS) Program Notice Of Provisional Approval Health Care Certification Exception Granted
  • 17-071
    PUB 470 (7/17) - Your Rights Under Adult Protective Services
  • 17-070
    Obsolete Form:  CF 377.2A (12/13) - CalFresh Notice Of Expiration Of Certification For Households In Which All Adults Are Elderly Or Disabled
  • 17-069
    CF 24 (6/17) - CalFresh Program Request For Policy/Regulation Interpretation
  • 17-068
    Obsolete Form:  CF 377.2A1 (4/14) - Important Information For Households In Which All Adults Are Elderly Or Disabled
  • 17-067
    LIC 9020 (5/17) - Register Of Facility Clients/Residents
    LIC 279A (5/17) - License Application And Instructions For Family Child Care Homes
  • 17-066
    LIC 421D (12/16) - Civil Penalty Assessment - Death
    LIC 421E (12/16) - Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse
  • 17-065
    LIC 421D (12/16) - Civil Penalty Assessment - Death
    LIC 421E (12/16) - Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse
    LIC 9099 (12/16) - Complaint Investigation Report
    LIC 9216 (3/17) - Complaint And Type A Violation Log
  • 17-064
    The Following Forms Are Now Obsolete:
    LIC 421 (12/15) - Civil Penalty Assessment
    LIC 421B (12/15) - Civil Penalty Assessment - Background Check/Child Care
    LIC 421C (12/16) - Civil Penalty Assessment - Immediate
    DFA 285C (4/99) - Food Stamp Supplemental Application For Special Medical Deductions
  • 17-063
    LIC 9020A (6/17) - Register Of Facility Residents - Residential Care Facilities For The Elderly
  • 17-062
    GEN 1391 (6/17) - CDSS eIEVS Access Request Form
  • 17-061
    LIC 622A (6/17) - Medication Administration Record (MAR)
    LIC 622B (5/17) - Psychotropic Medication Administration Record (MAR)
  • 17-060
    HCS 9184 (6/17) - Home Care Organization Disassociation Request
  • 17-059
    HCS 9183 (6/17) - Home Care Organization Association Request
  • 17-058
    NA 403A (4/17) Notice Of Action – Approval, Change Or Discontinued For Kinship - Guardians Only
  • 17-057
    NA 403 (4/17) Notice Of Action - For Resource Families, including homes certified by a Foster Family Agency, County Approved Relative Homes, Non-Relative
  • 17-056
    HCS 501 (6/17) - Personnel Record
  • 17-055
    RFA 812 (4/17) - Detail Supportive Information
    RFA 9099 (4/17) - Complaint Investigation Report
  • 17-054
    RFA 00 (4/17) - Conversion to Resource Family: Release of Information
  • 17-053
    RFA 09 (3/17) - Notice of Action Regarding Resource Family Approval
  • 17-052
    CCP 9 (4/17) - Child Care Program (CCP) 9 Request For Policy Interpretation
  • 17-051
    LIC 624-LE (4/17) - Law Enforcement Contact Report
  • 17-050
    PUB 470 (10/16) - Your Rights Under Adult Protective Services
  • 17-049
    EFA 14 (4/17) - Emergency Food Assistance Program (EFAP) 2017 Income Guidelines
    EFA 15 (4/17) - Alternate Pick-Up Request Form Emergency Food Assistance Program (EFAP) 2017 Income Guidelines
  • 17-048
    LIC 203 (2/93) - License To Operate A Facility
  • 17-047
    LIC 9223 (4/17) - Child Care Advocate Program
  • 14-046
    IHSS-E 006 (4/17) - In-Home Supportive Services Program Notice To Provider Of Expiration Of Exemption From Workweek Limits
    IHSS-E 007 (4/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Provider’s Expiration Of Exemption From Workweek Limits
  • 17-045
    IHSS-E 004 (4/17) - In-Home Supportive Services Program Notice Of Non-Receipt Of Exemption From Workweek Limits Provider Agreement (APD 006)
    IHSS-E 005 (1/17) - In-Home Supportive Services Program Notice Of Ineligibility To Request Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) - Provider
  • 17-044
    IHSS-E 002 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Provider For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances
    IHSS-E 003 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances
  • 17-043
    SR 1A (4/17) - Short-Term Residential Therapeutic Program (STRTP) Rate Application (SR 1A)
  • 17-042
    FCR 16 (4/17) - Group Home/Short Term Residential Therapeutic Program (STRTP) Shelter Costs Declaration And Survey
  • 17-041
    GEN 1031 (4/17) - Annual County Training Plan
  • 17-040
    LIC 989A (3/17) - Non-Confidential Records Request Form
  • 17-039
    GEN 1390 (3/17) - Informing Notice - Regarding An Action Taken On Your Case
  • 17-038
  • 17-037
    SOC 2300 (2/17) - In-Home Supportive Services Program Notice To Applicant Of Application Confirmation Number
  • 17-036
    PUB 271 (2/17) - Never Shake a Baby Brochure
  • 17-035
    PUB 490 (2/17) - Know Your Sexual and Reproductive Health Rights
  • 17-034
    LIC 00 (3/17) - Conversion To Resource Family: Release of Information
  • 17-033
    PUB 325 (12/16) - Your Right To Make Decisions About Medical Treatment (Print 8 1/2 X 14)
  • 17-032
    List Of Obsolete Forms - CW 2102, M44-314, M44-314A, M44-314B And M44-314C
  • 17-031
    AD 4320L (1/17) - Adoption Assistance Program (AAP) Agreement (18pt font)
  • 17-030
    AAP 6L (1/17) - Adoption Assistance Program Negotiated Benefit Amount and Approval (18pt font)
  • 17-029
    AAP 3L (12/16) - Reassessment Information - Adoption Assistance Program (18pt font)
  • 17-028
    RFA 01A (2/17) - Resource Family Application
  • 17-027
    PUB 510 (12/16) - Mandated Reporting
  • 17-026
    SOC 860 (12/16) - Sponsor's Statement Of Facts Income And Resources
  • 17-025
    CW 42 (9/16) - Statement of Facts - Homeless Assistance
  • 17-024
    M44-211D (11/16) - Temporary Shelter and/or Permanent Housing, Deny
  • 17-023
    SAR 2 (1/17) - Reporting Changes For Cash Aid And CalFresh
  • 17-022
    Number Not Used
  • 17-021
    GEN 1390 (1/17) - Informing Notice - Regarding An Action Taken On Your Case
  • 17-020
    GEN 1365 (12/16) - Notice of Language Services
  • 17-019
    RFA 00A (2/17) - Conversion - Resource Family Application
  • 17-018
    LIC 00A (2/17) - Conversion - Resource Family Application
  • 17-017
    PUB 273-A1 (1/17) - Shaken Baby Syndrome Poster - (10" x 12")
    PUB 273-A2 (1/17) - Shaken Baby Syndrome Poster - ( 24" x 36")
  • 17-016
    PUB 273 (1/17) - Shaken Baby Syndrome Poster - (8" x 11')
  • 17-015
    PUB 400C (1/17) - Safely Surrendered Baby Know Your Rights
    PUB 400C-1 (1/17) - Safely Surrendered Baby Law - Know Your Rights Poster
  • 17-014
    PUB 400 (1/17) - Safely Surrendered Baby Campaign Brochure
  • 17-013
    LIC 281D (1/17) - Application And Supporting Documentation Checklist Foster Family Agency
    LIC 281E (1/17) - Application And Supporting Documentation Checklist Short - Term Residential
  • 17-012
    LIC 01C (7/16) - Resource Family Application-Confidential
  • 17-011
    LIC 01A (2/17) - Resource Family Application
  • 17-010
    NA 403A (1/17) - Notice Of Action – Change For Kinship - Guardians Only
  • 17-009
    NA 403 (1/17) - NOTICE OF ACTION For Resource Families, including homes certified by a Foster Family Agency, County Approved Relative Homes, Non-Relative Extended Family Members, Foster Family Homes, Non-Related Legal Guardians
  • 17-008
    SOC 2299 (12/16) - In-Home Supportive Services (IHSS) Program And Waiver Personal Care Services (WPCS) Program Live-In Self-Certification Cancellation Form For IRS Federal Tax Wage Exclusion
  • 17-007
    SOC 2298 (12/16) - In-Home Supportive Services (IHSS) Program And Waiver Personal Care Services (WPCS) Program Live-In Self-Certification Form For IRS Federal Tax Wage Exclusion
  • 17-006
    PUB 429 (12/16) - California EITC is Here! Claim Your 2016 State And Federal Credits - You Earned It - It's Your Money
  • 17-005
    PUB 428 (12/16) - It's Your Money - Get It - The State and Federal Earned Income Tax Credit (EITCs)
  • 17-004
    PUB 467 (1/17) - Job Fair Flyer
  • 17-003
    PUB 428A (1/17) - Client Needs Survey
  • 17-002
    SOC 882 (12/16) - County CMIPS II User ID Confirmation CDSS Copy
  • 17-001
    M40-171D SAR (5/16) - Late SAR7/Restoration