How to fill out a LIC 500?

You must give the following information on the LIC 500 form: Employer information: The form must include the employer's name, address, and telephone number. Each employee's name and social security number. Dates of the pay period. Total number of hours worked by each employee during the pay period.

Get CA LIC 500 2003-2024

Q: What is LIC 500?

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.

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 facili.

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