2017 Notice Of Form Change

17-100
HCS 101 (10/17) - Home Care Aide Registration Renewal

17-099
M44-316C SAR (10/17) - No Change/Mid-Period Report of Property

17-098
LIC 610E-S (9/17) - Supplemental Emergency Disaster Plan For Residential Care Facilities For The Elderly

17-097
CF 303 (10/17) - Replacement Or Supplement Affidavit/Authorization

17-096
SOC 2320 (10/17) - In-Home Supportive Services (IHSS) And Waiver Personal Care Services (WPCS) CDSS Violation Removal Request

17-095
LIC 421CC (8/17) - Civil Penalty Assessment – Child Care

17-094
PUB 428 (10/17) - It's Your Money - Get It - The State and Federal Earned Income Tax Credit (EITCs)
PUB 429 (10/17) - California EITC is Here! Claim Your 2017 State And Federal Credits - You Earned It - It's Your Money

17-093
LIC 613C-2 (7/17) - Personal Rights In Privately Operated Residential Care Facilities For The Elderly

17-092
SOC 2265 (3/16) - In-Home Supportive Services Program Notice To Provider Reduction Of Total Violation Count

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