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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PRIVACY STATEMENT
Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code section 1798 et seq.),
notice is given for the request of the Social Security Number (SSN) on this form. The California Department of Justice uses a
person’s SSN as an identifying number. The requested SSN is voluntary. Failure to provide the SSN may delay the processing of
this form and the criminal record check.
In order to be licensed, work at, or be present at, a licensed facility, the law requires that you complete a criminal background
check. (Health and Safety Code sections 1522, 1568.09, 1569.17 and 1596.871). The Department will create a file concerning
your criminal background check that will contain certain documents, including information that you provide. You have the right to
access certain records containing your personal information maintained by the Department (Civil Code section 1798 et seq.).
Under the California Public Records Act, the Department may have to provide copies of some of the records in the file to
members of the public who ask for them, including newspaper and television reporters.
NOTE: IMPORTANT INFORMATION
The Department is required to tell people who ask, including the press, if some one in a licensed facility has a crminal record
exemption. The Department must also tell people who ask, the name of a licensed facility that has a licensee, employee,
resident, or other person with a criminal record exemption.
If you have any questions about this form, please contact your local licensing regional office.
LIC 198A (3/11) PAGE 2 OF 2