STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CRIMINAL BACKGROUND CLEARANCE TRANSFER REQUEST
Active criminal record clearances may be transferred from one state licensed facility/organization to another by a license
applicant or licensee. The transfer request must be submitted to the Department before the individual who is the
subject of the transfer has client contact or the facility/organization will be in violation of the law and subject to a
$100 civil penalty.
The license applicant or licensee who is seeking the transfer must provide a LIC 508, and verify the individual’s identity and
include a copy of the person’s driver’s license, permanent resident card or a valid photo identification issued by the
California Department of Motor Vehicles or by another state or the United States government if the person is not a California
resident. Additionally, a Child Abuse Central Index (CACI) check must be submitted if the transfer is to a facility serving
children and the individual has not previously submitted a CACI check or the date of the previous CACI inquiry was made
prior to January 1, 1999. The CACI must be mailed directly to the Department of Justice with the applicable fee. Note: This
transfer request is for clearances only. Contact your licensing office for information about exemption transfers.
This form may only be used to request a clearance transfer between state licensed facilities/organizations. To request a
transfer between county and state licensed facilities, the requesting Licensing Agency must contact their county liaison.
DATE:
PLEASE TYPE OR PRINT LEGIBLY
PLEASE TRANSFER THE CRIMINAL RECORD CLEARANCE FOR THE FOLLOWING INDIVIDUAL:
LAST NAME FIRST NAME MIDDLE INITIAL
CA DRIVER’S LICENSE OR ID #/PERMANENT RESIDENT ID# (i-551): DOB:
LICENSING INFORMATION SYSTEM ID#: SSN: (OPTIONAL)
FROM THE FOLLOWING FACILITY/ORGANIZATIONS:
NAME OF FACILITY/ORGANIZATION: FACILITY/ORGANIZATION NUMBER:
STREET ADDRESS:
CITY STATE ZIP CODE:
TO THE FOLLOWING FACILITY/ORGANIZATION:
D
PLEASE ALSO KEEP THIS INDIVIDUAL ASSOCIATED WITH
ABOVE FACILITY/ORGANIZATION.
NAME OF FACILITY/ORGANIZATION:
Transferee Association Type
D
Facility Administrator
D
Corporation Board Member
D
Employee
D
Certified Home
D
Licensee/Applicant
D
Non-client Adult Resident
D
Partnership Member
D
Spouse of Licensee
D
Affiliated Home Care Aide
FACILITY/ORGANIZATION NUMBER: DATE OF EMPLOYMENT:
STREET ADDRESS:
CITY STATE ZIP CODE:
I certify I have verified the above individual’s identity and have enclosed a copy
of the individual’s photo I.D and LIC 508.
Signature
Title (licensee, administrator, director)
FOR DISTRICT OFFICE USE ONLY
DATE OF TRANSFER ENTRY: INITIAL OF PERSON ENTERING TRANSFER:
FILE IN NEWLY ASSOCIATED FACILITY/ORGANIZATION FILE
LIC 9182 (11/15)
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/organization, the law requires that you complete a criminal
background check. (Health and Safety Code sections 1522, 1568.09, 1569.17, 1596.871 and 1796.19). 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 someone in a licensed facility/organization has a
criminal record exemption. The Department must also tell people who ask the name of a licensed facility/organization 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 9182 (11/15) PAGE 2 OF 2
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