Fillable PERSONNEL REPORT This form is intended for keeping (California)

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PERSONNEL REPORT This form is intended for keeping (California)

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A. STAFF SUBJECT TO CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following staff members are subject to a criminal background check pursuant to Sections 1522, 1568.09, 1569.17 and
1596.871 of the Health and Safety Code. A California background clearance or a criminal record exemption shall be obtained prior to employment, residence or initial presence in the facility.
SPECIFY
DAYS AND HOURS ON DUTY
DAYS FROM TO
STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERSONNEL REPORT
INSTRUCTIONS:
This form is intended for keeping a current roster of all the facility personnel, other adults and licensees residing in the facility,
including backup persons, volunteers and licensee if administrator/director. Show license/certificate number if applicable for
specialized staff [e.g., Social Worker and other consultant(s)]. Show coverage for twenty-four hour supervision in residential
facilities. Report any changes in personnel to the licensing agency as required by regulations. Send original to Licensing
Agency and retain copy in facility file.
NAME OF FACILITY
PREPARED BY DATE
FACILITY TYPE FACILITY NUMBER
NAME
Licensee/Administrator
DATE
EMPL'D
JOB TITLE
SPECIFY
DAYS AND HOURS ON DUTY
DAYS FROM TO
SPECIFY
DAYS AND HOURS ON DUTY
DAYS FROM TO
LIC 500 (11/03) (PUBLIC)
Page 1 of 2
SPECIFY
DAYS AND HOURS ON DUTY
DAYS FROM TO
SPECIFY
DAYS AND HOURS ON DUTY
DAYS FROM TO
SPECIFY
DAYS AND HOURS ON DUTY
DAYS FROM TO
NAME
B. STAFF EXEMPT FROM CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following are believed exempt from criminal background check requirements pursuant to Sections 1522, 1568.09,
1569.17 and 1596.871 of the Health and Safety Code. The licensee or designated representative shall sign below to verify that he or she believes the indicated persons are exempt from criminal background
check requirements pursuant to statute.
DATE
EMPL'D
JOB TITLE
Signature
________________________________________________________________________________ Date __________________
Page 2 of 2
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Completed 18 December 2020

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