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LIC 9163: Request for Live Scan Service - Community Care Licensing

By Sevana Care · Checked against cdss.ca.gov and Title 22 on

When it is due
Before the person's first presence in the home.The licensee submits the fingerprint images "prior to the person's employment, residence, or initial presence in the residential care facility for the elderly" [7]. The statute also requires a clearance or exemption before the person's initial presence [7]. These rules set the time for the fingerprints; they do not name LIC 9163 [3][7].
Who fills it out
The person being fingerprinted fills in the applicant items and signs.The Live Scan operator completes item 8 [1]. CDSS says to use the form the employer, licensee or provider gives you [8].
Where it is kept
The form says the operator keeps one copy and the applicant "may retain" the other [1].Title 22 asks the home to keep documentation of the clearance or exemption in the personnel record and does not name this form [3][6]. An administrator certificate application includes the form signed by the Live Scan vendor, or a statement that a clearance or exemption is already on file [5].
How long to keep
Neither the form nor § 87355 sets a period for it [1][3].Section 87412(h) sets three years after employment ends for personnel records, and § 87412 does not name LIC 9163 [6].

LIC 9163 is the California Department of Social Services (CDSS) form a person takes to a Live Scan site to be fingerprinted for a background check. The site sends the fingerprints electronically to the California Department of Justice (DOJ) [8]. Page 2 of the form lists "Residential Care Facilities for the Elderly" beside the DOJ facility type "Residential Care Facility Elderly" [1]. Title 22 § 87102(g) lists the form among those "incorporated, in their entirety, by reference," at an older revision, (3/11) [4].

Who fills it out

The form's instructions give directions for items 2, 3, 5, 6 and 7. Items 1 and 4 are preprinted. The Live Scan operator completes item 8 [1]:

  • Item 2, working title: boxes include Employee, Volunteer and Adult Resident other than Client.
  • Item 3, authorized applicant type: for an RCFE, "Residential Care Facility Elderly" from the table on page 2.
  • Item 5, applicant information: name, birth date, sex and other personal details, and the applicant's signature and date. The signature acknowledges the privacy notices. The Social Security number is optional.
  • Item 6, facility number, and item 7, the employer's name and address.
  • Item 8, operator section: name, date, transmitting agency, LSID and ATI numbers, and the amount collected or billed.

CDSS says: "It is very important for you to use only the Live Scan form provided to you by the potential employer, licensee or provider." It adds that the forms hold information unique to each agency, which must be on the form before the person arrives [8]. The form's top note says an applicant who intends to use Guardian, the CDSS system used for background checks [9], should start at the Guardian Applicant site, where a prepopulated form is available [1].

Who is fingerprinted. Health and Safety Code (HSC) § 1569.17(b) also covers these people, among others [7]:

  • an administrator, supervisor, manager or director, and an adult responsible for running the facility or directly supervising staff
  • a person who is not a client and lives in the facility
  • a person who helps clients with dressing, grooming, bathing or personal hygiene
  • a staff person, volunteer or employee who has contact with the clients

Section 1569.17(b)(2) lists people who are exempt, with conditions, such as a volunteer who meets all five listed conditions [7].

When it is due

Before the person's first presence in the home. HSC § 1569.17 says: "An individual shall be required to obtain either a criminal record clearance or a criminal record exemption from the State Department of Social Services before their initial presence in a residential care facility for the elderly" [7]. Section 87355(d)(3) says the licensee submits the fingerprints "prior to the individual's employment, residence, or initial presence in the facility" [3].

How long the check takes. The statute says: "Within 14 calendar days of the receipt of the fingerprint images, the Department of Justice shall notify the State Department of Social Services of the criminal record information" [7]. CDSS's estimates, with no criminal history, are about 3 days for DOJ, about 5 days for the FBI, and 4 to 6 weeks for a Child Abuse Central Index check, where one applies. CDSS adds that time frames "will be significantly longer if the applicant has a criminal history or if a fingerprint/Live Scan transmittal is rejected" [8].

If the fingerprints are rejected. Item 6 asks for the original ATI number on a resubmission, and the person "must present proof of rejection." The instructions cover a resubmission "for fingerprint quality" and say to enter the number from the reject notice "to avoid paying an additional processing fee" [1].

The penalty. Section 87355(e) lists steps a person must take "prior to working, residing or volunteering in a licensed facility." Section 87355(f) says a violation of § 87355(e) "shall result in a citation of a deficiency and an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days" [3]. Section 87355(f)(1) adds: "Subsequent violations within a twelve (12) month period will result in a civil penalty of one hundred dollars ($100) per violation per day for a maximum of thirty (30) days" [3]. HSC § 1569.17(c)(1)(B) sets the same amounts and day caps for a licensee's failure to submit the fingerprint images [7].

Where it is kept

The applicant's copy. The form says: "Take two copies of this form with you the day you are fingerprinted. The Live Scan Operator will complete section 8. One copy will be retained by the Operator and the other you may retain for your records" [1].

The home's record. Section 87355(j) says the licensee "shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file" [3]. Section 87412(a)(13)(B) puts "Documentation of either a criminal record clearance or a criminal record exemption" in the personnel record of each employee who must be fingerprinted, and § 87412(b)(3) says the same for volunteers [6]. Neither section names the Live Scan form [3][6]. CDSS's list of records an RCFE keeps, dated 4/05, names "Criminal Record Clearance or Exemption" under "Personnel Records" and no form number [12].

Administrator certificate applicants. Section 87406(b)(3)(G) says the application shall contain "A completed Request for Live Scan Service form LIC 9163, signed and dated by the live scan vendor," or a statement that the applicant already has a clearance or exemption on file [5].

How long to keep it. Neither the form [1] nor § 87355 [3] gives a period. Section 87412(h): "All personnel records shall be retained for at least three (3) years following termination of employment" [6]. Section 87412 does not name LIC 9163 [6].

What the record must show

For an employee who must be fingerprinted, § 87412(a)(13) requires the personnel record to hold [6]:

  • a signed statement about their criminal record history, "as required by Section 87355(d)"
  • documentation of either a criminal record clearance or a criminal record exemption, "as required by Section 87355(e)"

HSC § 1569.17(c)(1)(A), as amended effective September 18, 2026, says: "The department shall not require the person to disclose their criminal history information prior to receipt of live scan results" [7].

Section 87412(a)(13)(B) asks for "Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e)." Item 1 under it says: "For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement" [6].

Questions

Is LIC 9163 the only Live Scan form?

CDSS's Live Scan page and its form list name LIC 9163 [8][2]. CDSS's Fingerprinting page says the process begins with "Request for Live Scan Service form (BCIA 8016)," the DOJ's form, and links LIC 9163 under "Additional Information" [13]. The list also holds LIC 9163B, "Request Live Scan Service - Long Term Care OMBUDSMAN," a separate form [2].

Does Guardian replace LIC 9163?

CDSS says: "Using Guardian does not replace the Live Scan process or the fingerprint fees. Guardian will generate a pre-populated Live Scan form after an application has been completed" [9].

Does a person with an active clearance need new fingerprints?

CDSS says: "If an individual has an active clearance, he/she should not be re-fingerprinted as this may delay the processing of the transfer" [11]. Section 87355(c) covers the transfer request. See LIC 9182.

Why does Title 22 list a different revision?

Section 87102(g) lists "LIC 9163 (3/11)" [4]. The CDSS list shows (11/25) [2]. CDSS's Provider Information Notice (PIN) 24-10-CCLD says "individuals are strongly encouraged to use the new version of the applicable form when submitting outside of the Department's online portal" [10].

How Sevana Care keeps this record

Credential expiry dates are easy to lose track of. The Team page in Sevana Care lists each staff member's credentials by type, including background check and fingerprinting (LiveScan), and marks each Current, Expires soon, Expired or No expiry. The inspection check on staff credentials flags any that have expired. If none have, it flags any that expire within 30 days. We don't fill in the LIC 9163. Open the Team page in the sample home to see the statuses.

More in Staff and background checks

  • LIC 500: The roster of staff, volunteers and other adults in the home, with duty hours
  • SOC 341A: The mandated reporter statement a new employee signs

Sources

  1. CDSS, LIC 9163 (11/25), Request for Live Scan Service - Community Care Licensing (PDF)
  2. CDSS, Forms and Publications (I-L)
  3. California Code of Regulations, Title 22, § 87355, Criminal Record Clearance (Westlaw)
  4. California Code of Regulations, Title 22, § 87102, Descriptions of Forms (Westlaw)
  5. California Code of Regulations, Title 22, § 87406, Administrator Certification Requirements (Westlaw)
  6. California Code of Regulations, Title 22, § 87412, Personnel Records (Westlaw)
  7. Health and Safety Code § 1569.17 (leginfo.legislature.ca.gov)
  8. CDSS, Live Scan Application Process and Associated Fees
  9. CDSS, Guardian FAQs
  10. CDSS, PIN 24-10-CCLD, Care Provider Management Branch Background Check Form Revisions (PDF)
  11. CDSS, Transferring a Clearance to a New Facility
  12. CDSS, LIC 311F (4/05), Records To Be Maintained At The Facility, Residential Care Facility For The Elderly (PDF)
  13. CDSS, Fingerprinting