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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
FACILITIES STAFF WORK SCHEDULE
INSTRUCTIONS: This form is to be completed by the licensing evaluator and reviewed by the licensing supervisor.
The purpose of this form is to review staff coverage in large Residential Facilities for 24-hours per day covering a (3) three-week period to
ensure sufficient staff coverage. CAREFULLY review split shifts
, weekend coverage and irregular days off to ensure sufficient staff coverage.
1. Care and Supervision (e.g., Aides)
Employee Name(s)
2. Food Services (e.g, includes cook, dishwasher)
Employee Name(s)
FACILITY NAME
CLIENT/RESIDENT CENSUS LICENSING EVALUATOR DATE
FACILITY NUMBER FACILITY TYPE FACILITY CAPACITY
For The Month(s) 20
Sun Mon Tues
Wed Thurs Fri
Sat Sun Mon
Tues
Wed
Thurs
Fri Sat Sun
Mon
Tues
Wed
Thurs
Fri
Sat
LIC 507 (1/00)
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SERVICE AREA AND WORK TITLE
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