Fillable Form 1.: APPLICATION FOR A FAMILY CHILD CARE (California)

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Form 1.: APPLICATION FOR A FAMILY CHILD CARE (California)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
APPLICATION FOR A FAMILY CHILD CARE HOME LICENSE
Type or print clearly.
1.
TYPE OF APPLICATION
AGENCY USE ONLY
NUMBER:
TYPE:
TYPE OF LICENSE: LICENSE #:
LICENSING AGENCY:
ADDRESS:
PHONE:
PHONE:
CITY STATE ZIP
CITY COUNTY STATE ZIP
CITY
STATE
ZIP
DATE LICENSED/CERTIFIED:
ASSIGN:
Middle
First Name Middle
Applicant(s) Signatures City and County where Signed Date
Last Name Relationship to You
Last Name Over 18 Years Old?
■
New Application
■
Capacity Change
■
Location Change
■
Update
6. ARE YOU CURRENTLY, OR HAVE YOU EVER BEEN, LICENSED OR CERTIFIED FOR ANY TYPE OF
FACILITY TO CARE FOR CHILDREN OR ADULTS?
3a.
YOUR HOME ADDRESS:
3b. IF YOU HAVE NOT LIVED IN THIS COUNTY FOR THE PAST TWO YEARS, LIST
THE COUNTIES IN WHICH YOU HAVE RESIDED:
5
. DIRECTION(S) TO HOME:
4. MAILING ADDRESS (if different):
AGES TO BE SERVED: DAYS & HOURS OPEN:
LIC 279 (2/09) PAGE 1 OF 2
7. OTHER ADULTS IN THE HOME (Not applicant(s)) Do not list the names of persons under 18 years of age
9. TYPE OF LICENSE
■
Small Home (up to 8)
■
Large Home (up to 14)
10. APPLICANT/LICENSEE RESPONSIBILITY - I/We certify that:
A. I/We live in the home to be licensed.
B. I/We have money to maintain the level of service required by law in a Family Child Care Home.
C. I/We have both a State Fire Marshal approved fire extinguisher (rated 2A, 10B: C) and a smoke detector in operating condition.
D. I/We shall stay current and in compliance with the laws and regulations governing standards for Family Child CareHomes.
E. I/We shall obtain approval from the licensing agency before making changes in our license capacity, or to our home.
F. I/We shall notify the licensing agency when we want to discontinue our license.
G. I/We have informed the property owner, if leased or rented, that we will be operating a Family Child Care Home on the premises.
The owner/landlord has been sent the Property Owner/Landlord Notification (LIC 9151).
H. I/We have written consent from the property owner, if leased or rented, when I plan to expand my Small Family Child Care Home
capacity from 6 to 8 children, or to expand my Large Family Child Care Home capacity from 12 to 14 children. Property
Owner/Landlord Consent Form (LIC 9149).
I. I/We understand the requirements to report known or suspected child abuse (LIC 9108).
11. PERJURY STATEMENT - I/We declare under penalty of perjury that the statements on this application and accompanying
attachments are correct to the best of my/our knowledge.
■
Yes
■
No
■
Pending
Did you remember to: Sign and date all documents in ink and enclose the application/licensing fee?
8. CURRENT CHILDREN IN YOUR HOME (LIC 279B) Click to access
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
2.
APPLICANT(S) First
EMAIL ADDRESS (NOT REQUIRED)
Need Help Completing The
Application For a Family Child Care Home License?
These are instructions for filling out the Application for a Family Child Care Home License (LIC 279).
Match the numbered items on this page with the numbered sections on the Application.
For your information, details on the Application are public information.
1. TYPE APPLICATION - A “New Application” is a request to license both an individual and a home that
are not now licensed. A “Capacity Change” is a request to increase the approved number of children in
an already licensed home. A “Location Change” is a request by a licensee to obtain a new license
when he/she plans to move. An “Update” is, for example, to request a change in your name or phone
number.
2. APPLICANTS - The applicants are the persons who will be responsible for providing child care in their
own home. All applicants must live in the home to be licensed and must be 18 years of age or older to
be licensed to provide child care. A “Yes” check means the applicants are 18 years of age or older.
3a. YOUR HOME ADDRESS - Your home address is the location of the home in which you live and want
to provide care. This is the home that the Licensing Agency will inspect to determine whether it meets
health and safety standards. PHONE NUMBER--Enter your primary phone number.
3b. LIST OF ADDITIONAL COUNTIES - If you have not lived in this county for two years, list all other
counties where you have lived in the past two years.
4. MAILING ADDRESS - If your mailing address is different from the home address, put your mailing
address here. If it is the same, write "Same". EMAIL ADDRESS--It is not a required field to complete.
5. DIRECTION(S) TO HOME - Please provide directions to your home. Please attach a sketch or map if
possible.
6. LICENSE OR CERTIFICATION STATUS - This is any license or certification issued to any of the
applicants for providing care. If you are or have ever been licensed or certified to provide care, or if an
application is pending, check the appropriate box and enter the type of license/certification; date
licensed/certified; and name, address and phone number of the Licensing Agency. This includes
Foster Family Homes and any other license category.
7. OTHER ADULTS IN THE HOME - List all persons (other than yourself) who live in your home,
including family members, boarders, or other relatives. Do not list the names of persons under 18
years of age (See #8 below). If needed, you may attach additional pages to list all residents. You do
not need to list your spouse if he/she is also an applicant.
8. CURRENT CHILDREN IN YOUR HOME - Complete the form LIC 279B. List the name, date of birth,
sex and relationship of each child living in your home. This sheet will be filed in the confidential portion
of your facility file.
9. TYPE OF LICENSE - Requirements for homes serving nine or more children are different from homes
serving eight or fewer. Please tell us the capacity you plan to serve, the age range, and what days
and/or hours you plan to be open.
10. APPLICANT/LICENSEE RESPONSIBILITY - You need to let the Licensing Agency know that you live
in the home to be licensed, have enough money to maintain your home, have basic fire protection, will
stay current and in compliance with licensing laws and regulations, will obtain approval from the
licensing agency whenever you plan to change your license capacity or make changes to your home,
and that you understand the child abuse reporting requirements and the notification and consent
requirements related to property owners/landlords.
11. PERJURY STATEMENT - Each applicant must sign the application. The signatures should be the
same as the names listed on the top of the form. The signature is signed under a perjury oath. This
means that you promise that everything you have said in the application is true and correct. If you
knowingly make false statements, you have committed the crime of perjury, which may be punishable
by imprisonment.
NOTE: IF YOU DO NOT HAVE ENOUGH SPACE, ATTACH ADDITIONAL PAPER.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
LIC 279 (2/09) PAGE 2 OF 2
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Form 1.: APPLICATION FOR A FAMILY CHILD CARE (California)

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Completed 1 October 2020

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