STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS
I, as the parent/legal guardian of _____________________________________ , currently attending or newly enrolled at
______________________________ child care center/family child care home acknowledge I have received the following
information as required by Health and Safety Code sections 1596.8595 and 1596.8895.
■ Copy of any licensing report that documents a Type A deficiency cited at this facility; Type A deficiencies are those that,
if not corrected, represent an immediate risk to the health, safety or personal rights of children in care. This includes
facility visits and substantiated complaint investigations.
Date(s) of licensing report(s) provided: ________________________________________________________
■ Copy of licensing documents pertaining to a conference conducted by a local licensing agency management
representative and the licensee of this child care center/family child care home in which issues of noncompliance are
discussed.
Date of document provided: ____________________________
■ Copy of the Accusation Summary indicating the Department’s intent to revoke the license of this child care
center/family child care home, until that accusation is either dismissed or resolved through the administrative hearing
process or stipulated agreement.
Date of document provided: ________________________
■ As a parent/legal guardian of a newly enrolled child in this child care center/family child care home, I have been pro-
vided the documents identified above received by the licensee during the 12-month period prior to my child’s enroll-
ment.
My signature below verifies I have received the documents identified above.
PARENT/LEGAL GUARDIAN SIGNATURE:
DATE DOCUMENTS RECEIVED:
LIC 9224 (8/08)
