STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FAMILY CHILD CARE HOME
ADDENDUM TO NOTIFICATION OF PARENTS’ RIGHTS
(REGARDING REMOVAL/EXCLUSION)
California State law requires the licensee to notify you that the person whose name appears below has been
removed or excluded from this Family Child Care Home.
Name:
_____________________________________________________
Effective Date:
_____________________________________________________
This person is not permitted to be in the home at any time when children are in care. This
removed/excluded person may be an ex-employee, friend or relative of the licensee. This person has a right
to appeal the exclusion. If he/she is later permitted back into the Family Child Care Home you will be
notified.
The local licensing office listed below maintains a public file on this facility. Parents, domestic partners or
authorized representatives may review the public file for any documents related to this action. You should
know that many documents are protected by confidentiality laws and will not be available for review.
Licensing Office Name:
_____________________________________________________
Licensing Office Address:
_____________________________________________________
City/State/Zip:
_____________________________________________________
Name And Address of This Facility
Facility Name:
_____________________________________________________
Facility Address:
_____________________________________________________
City/State/Zip:
_____________________________________________________
ACKNOWLEDGMENT OF
ADDENDUM TO NOTIFICATION OF PARENTS’ RIGHTS
(REGARDING REMOVAL/EXCLUSION)
This will acknowledge that I, the parent/authorized representative of ______________________,
have received a copy of the “ADDENDUM TO NOTIFICATION OF PARENTS’ RIGHTS
(REGARDING REMOVAL/EXCLUSION)” from the licensee or designated representative.
(Parent
/Authorized Representative signature is required)
.
______________________________________________ _______________________
Signature of Parent/Authorized Representative Date
NOTE: This form with the original signature of the parent/authorized representative must be kept in
the child’s file. A copy of this form must be given to the parent/authorized representative.
LIC 995B (8/08)
