NAME: LAST FIRST MIDDLE
FOR LICENSING OFFICE USE ONLY
FOR FOLLOW-UP ONLY
Original Date Sent
Date Re-sent_
MAIDEN NAME: NAME/AKA:
NAME/AKA: NAME/AKA:
CURRENT ADDRESS STREET CITY STATE ZIP CODE
FACILITY TELEPHONE NUMBER DRIVER'S LICENSE NUMBER
A
FACILITY ADMINISTRATOR/DIRECTOR
C
CORPORATION BOARD MEMBER
E
EMPLOYEE
PERSONNEL TYPE OPTIONS
F
CERTIFIED HOME (FFA)
L
LICENSEE/APPLICANT
N
NONCLIENT ADULT RESIDENT
P
PARTNERSHIP MEMBER
S
SPOUSE OF LICENSEE
(Unless included as a
licensee)
U
UNKNOWN
SOCIAL SECURITY NUMBER - SEE PRIVACY STATEMENT ON PAGE 2.
DATE OF BIRTH —
MO., DAY, YEAR
FACILITY NUMBER:
________________________________________________________________________________________
FACILITY NAME:
________________________________________________________________________________________
FACILITY ADDRESS:
________________________________________________________________________________________
STREET CITY STATE ZIP CODE
FOR DEPARTMENT OF JUSTICE USE ONLY
The result of a name search in the Child Abuse Central Index is as follows:
The subject of the attached report MAY be the same as the subject of your inquiry.
No record on the above listed person.
Too many possible matches to identify. See attached listing.
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHILD ABUSE CENTRAL INDEX CHECK FOR
STATE LICENSED FACILITIES
DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
CAREGIVER BACKGROUND CHECK BUREAU
744 P ST., MS 9-15-62
SACRAMENTO, CA 95814
All persons subject to a background check are also subject to a Child Abuse Central Index (CACI) check, if the facility to which they are
associated provides care and supervision to children. This includes all child care centers; family child care homes;
children’s residential homes and facilities; and adult residential facilities if, through an approved exception or a specialized
license, they provide care to a person under age 18.
If the person is submitting fingerprints for a criminal record background check, a request for a check of the CACI will be transmitted to the
Department of Justice at the same time.
If a CACI check is required subsequent to a California Department of Social Services (CDSS) processed criminal record
background check, it is the licensee’s responsiblity to submit this form and appropriate fees directly to the Department of
Justice, P. O. Box 903417, Sacramento, CA 94203-4170.
TYPE OR PRINT INFORMATION
List all other names you have ever used:
MALE
FEMALE
LIC 198A (3/11)
Complete ALL items checked (✔)
Include $15.00 for each Child Abuse Central Index
Check. (There is no exemption from this fee) Make
check or money order payable to the Department
of Justice.
DATE SENT
PAG E 1 OF 2
