Forms library
LIC 500: Personnel Report
By Sevana Care · Checked against cdss.ca.gov and Title 22 on
- When it is due
- The sources set no number of days.CDSS asks for it with a license application [4], and its entrance checklist lists it among the items a licensing analyst requests at the start of an inspection [5]. The form says "Report any changes in personnel to the licensing agency as required by regulations" and names no section [1]. Title 22 §§ 87211, 87411 and 87412 name no personnel report [8][7][6]. Section 87211(g) does set a 30-day written notice for a new administrator [8].
- Who fills it out
- The form has a "PREPARED BY" line but does not say who prepares it [1].If any staff are listed as exempt from the criminal background check, "the licensee or designated representative shall sign" [1].
LIC 500 is the California Department of Social Services (CDSS) Personnel Report. The form says it 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" [1]. CDSS's list of RCFE records calls it the "roster of current personnel" [3]. The Title 22 sections on personnel records, personnel requirements and reports do not name it [6][7][8].
Who fills it out
The form has a "PREPARED BY" line and a date [1]. It does not say who must prepare it.
The form lists staff in two parts [1]:
- Part A, "STAFF SUBJECT TO CRIMINAL BACKGROUND CHECK REQUIREMENTS." The first printed row is "Licensee/Administrator."
- Part B, "STAFF EXEMPT FROM CRIMINAL BACKGROUND CHECK REQUIREMENTS." The form says: "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." It has a signature line and a date.
CDSS's application instructions say to sign the reverse side "by the applicant/licensee or designated representative if there are exempt personnel at the facility," and that the licensing agency "will NOT accept photocopied signatures on this form." They also say that "If the applicant is the licensee of another facility, a separate LIC 500 must also be submitted for each licensed facility" [4].
When it is due
The sources set no number of days. The form gives none [1]. Sections 87211, 87411 and 87412 of Title 22 name no personnel report and no due date for one [8][7][6].
With a license application. CDSS's application instructions list LIC 500 as a required form for an RCFE application [4]. They say: "All planned employee positions are to be shown on this form. Include days and hours staff will be scheduled for duty." The director or administrator and any staff hired at that time go on it. "Other positions with staff not yet hired must be listed as "to be hired" and designated by position title" [4]. They add that job descriptions "will be compared to the Personnel Report (LIC 500) and there must be a job description for each classification listed on the LIC 500" [4].
At an inspection. CDSS's entrance checklist for RCFEs lists "Personnel Report (LIC 500*)" among the items requested from the facility on entrance. The checklist says "Asterisk (*) indicates other verifying documents may be substituted for form" [5].
When staff change. The form says: "Report any changes in personnel to the licensing agency as required by regulations." It names no regulation and gives no number of days [1]. Title 22 has two staff-change notices, and neither names LIC 500. Section 87211(g): "The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator." Section 87211(h): a change in the chief corporate officer of an organization, corporation or association "shall be reported to the licensing agency in writing within fifteen (15) working days following such change" [8].
Where it is kept
The form says: "Send original to Licensing Agency and retain copy in facility file" [1].
CDSS's list of RCFE records puts "Personnel Report-roster of current personnel (LIC 500)" under "Administrative Records." CDSS says the records on the list "must be kept in the facility complete and current, and readily available for review." The list is dated 4/05 [3].
How long to keep it. The form and CDSS's list give no period [1][3]. Section 87412 covers "personnel records" kept for "the licensee, administrator and each employee," and § 87412(h) says they "shall be retained for at least three (3) years following termination of employment" [6]. CDSS's list files LIC 500 under administrative records, not personnel records [3].
What the record must show
The top of the form asks for the facility name, facility type, facility number, who prepared it, and the date [1].
Each row asks for the person's name, the date employed, the job title, and the days and hours on duty. Each row has room for three sets of days, "from" and "to" times [1].
The instructions add [1]:
- "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."
Part A says staff "are subject to a criminal background check pursuant to Sections 1522, 1568.09, 1569.17 and 1596.871 of the Health and Safety Code." It adds: "A California background clearance or a criminal record exemption shall be obtained prior to employment, residence or initial presence in the facility" [1]. Title 22 § 87411(g) says employees and volunteers subject to a criminal record review must obtain a California clearance or a criminal record exemption, or request a transfer of one, before employment or initial presence [7].
Hours. LIC 500 lists days and hours on duty. Section 87412(e) says "personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked" [6]. CDSS's list has a separate line, "Reports of actual hours worked by staff," under "Personnel Records" [3].
Questions
Does an RCFE have to use LIC 500?
Sections 87211, 87411 and 87412 of Title 22 name no form [8][7][6]. CDSS lists LIC 500 in the records an RCFE keeps [3], and marks it "Required" for a license application [4]. The entrance checklist says other verifying documents may be substituted for the form [5].
Is LIC 500 the staff work schedule?
CDSS lists a separate form, "LIC 507 (1/00) - Facilities Staff Work Schedule" [2]. CDSS's list of RCFE records has its own line for the "Dated weekly employee time schedule posted in facilities for 16 or more residents" and names no form there [3]. No source says LIC 500 replaces either one.
Who goes in Part B?
The form says the people "believed exempt" under Health and Safety Code §§ 1522, 1568.09, 1569.17 and 1596.871 [1]. CDSS's application instructions say the licensing agency "will make sure anyone designated as EXEMPT from fingerprinting requirements is appropriate pursuant to Health and Safety Code Sections 1522 and 1569.17" [4]. CDSS's list of RCFE records also has its own line: "Licensee affidavit on persons exempt from fingerprint requirements (if not on LIC 500)" [3]. So the exempt staff can be recorded on LIC 500 or in a separate affidavit.
How Sevana Care keeps this record
Staff lists go stale fast. Sevana Care's Team page lists the people in the home with their role, their sign-in where they have one, and their credentials. A Schedule tab sits beside it. We have no LIC 500 form and no spot to file one. See the Team page and its Schedule tab in the sample home.
More in Staff and background checks
Sources
- CDSS, LIC 500 (11/03), Personnel Report (PDF)
- CDSS, Forms and Publications (I-L)
- CDSS, LIC 311F (4/05), Records To Be Maintained At The Facility, Residential Care Facility For The Elderly (PDF)
- CDSS, LIC 281 (11/25), Application Instructions for a Facility License (PDF)
- CDSS, LIC 9242 (9/19), Entrance Checklist, Residential Care Facilities for the Elderly (PDF)
- California Code of Regulations, Title 22, § 87412, Personnel Records (Westlaw)
- California Code of Regulations, Title 22, § 87411, Personnel Requirements--General (Westlaw)
- California Code of Regulations, Title 22, § 87211, Reporting Requirements (Westlaw)