LIC 501: Personnel Record

The employee. The form's heading reads "PERSONNEL RECORD (Form to be completed by employee)" ^[1]. At the bottom the employee signs under this statement: "I hereby certify under penalty of perjury that the above statements are true and correct. I give my permission for any necessary verification" ^[1]. The form does not say who reviews it.

CDSS's application instructions add: "Only those who do not complete an LIC 215 should complete this form." They say the form is "signed and submitted to the licensing agency with the application only for directors/administrators or Group Home program managers who are not licensees" ^[4].

The sources set no number of days. The form gives none ^[1]. Section 87412 says what a personnel record holds and when records are kept, and gives no day count for completing one ^[5].

With a license application. CDSS's application instructions list LIC 501 as a required form for an RCFE application ^[4]. They limit who submits it then: "only for directors/administrators or Group Home program managers who are not licensees. All other staff forms are to be kept on file for review at the facility." They add: "Verification of education and experience will be done against official transcripts and/or references" ^[4].

After hire. The form asks for the "DATE OF EMPLOYMENT" ^[1]. Section 87412(a)(3) puts the date of employment in the personnel record ^[5]. Neither says how soon after that date the record must be complete.

Section 87412(a) requires a personnel record for the licensee, the administrator and each employee ^[5]. Section 87412(g): "All personnel records shall be maintained at the facility." The licensee may use a central administrative location "provided that they are readily available to the licensing agency at the facility" ^[5]. Section 87412(f) makes the records available to the licensing agency "to inspect, audit, and copy upon demand during normal business hours" ^[5].

CDSS's list of RCFE records puts the "Personnel Record (employment application) form (LIC 501)" under "Personnel Records." The list is dated 4/05 ^[3].

How long to keep it. Section 87412(h): "All personnel records shall be retained for at least three (3) years following termination of employment" ^[5].

The form has six parts and a signature ^[1]:

1. Personal: name, address, telephone, an age question, Social Security number, the date of the last physical examination and of the last TB test, other names used, driver's license questions, and the nearest living relative.
2. Position: title, salary, hours, date of employment and supervisor.
3. Previous employment: employer, telephone, job title and type of work, reason for leaving, and dates.
4. Education: the highest year completed, diploma, related courses, and college or business school.
5. References: three people who can speak to the person's background, character and abilities.
6. Professional and technical qualifications: licenses or certificates, and professional associations.

Items in § 87412(a) that the form asks about ^[5][1]:

• The full name, home address and telephone number.
• The date of employment and the type of position.
• Educational background.
• Past experience, including types of employment and former employers.
• The Social Security number.

Items in § 87412(a) the form does not cover ^[5][1]:

• Written verification of age. The form asks "ARE YOU 18 YEARS OF AGE OR OLDER?" and, if not, for the age. The rule asks for "Written verification that the employee is at least 18 years of age, including, but not necessarily limited to, a copy of his/her birth certificate or driver's license." CDSS's list puts "For the administrator, supervisors and staff who supervise or care for residents, verification of age 18, education, and experience requirements" on its own line ^[3].
• A health screening. The form asks for the date of the last physical examination and TB test. The rule asks for "A health screening as specified in Section 87411" ^[5]. CDSS lists LIC 503 on its own line ^[3].
• Criminal record documents for staff who must be fingerprinted (item (a)(13)), and training records (§ 87412(c)) ^[5].
• "Hazardous health conditions documents as specified in Section 87411" (item (a)(12)). For administrators, item (a)(6)(A) adds "verification that he/she meets the educational requirements in Section 87405(d) through (g)" ^[5].
• The termination date "if no longer employed by the facility," and the reasons for leaving (items (a)(9) and (a)(10)). The form's "reason for leaving" column is for earlier jobs ^[5][1].