LIC 500 Personnel Report

What Is LIC 500 Personnel Report Form?

LIC 500 is the California Department of Social Services Personnel Report for facility personnel and other persons specified in its instructions. 

What Is LIC 500 Personnel Report Form Used For?

LIC 500 is the California Department of Social Services Personnel Report. Its instructions say it 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 the licensee if administrator/director.

How to Fill Out LIC 500 Personnel Report Form?

• Enter the name of the facility, facility type, facility number, who prepared the report and the date.
• Section A lists staff subject to criminal background check requirements (Health and Safety Code sections 1522, 1568.09, 1569.17 and 1596.871): name, job title, date employed, and the days and hours on duty.
• Section B lists staff believed exempt from those requirements, with the same details.
• Show the license or certificate number of specialized staff where applicable, and, in residential facilities, show coverage for twenty-four hour supervision.

How to Submit the LIC 500 Personnel Report Form?

The form says to send the original to the licensing agency and retain a copy in the facility file, and to report any changes in personnel to the licensing agency as required by regulations.

Who Should Sign the LIC 500 Personnel Report Form?

The licensee or designated representative signs Section B to verify that he or she believes the indicated persons are exempt from criminal background check requirements.