Get CA HHSA DSS LIC 601 2008-2024

COMMENTS SIGNATURE OF RESIDENT LIC 601 8/08 Personal TITLE DATE Page 1 of 2 B. RESIDENTIAL FACILITIES FOR CHILDREN Additional information is required by regulation for residential facilities for children. NAME OF CHILD SPECIFY RELATIONSHIP TELEPHONE NUMBER 4. All information must be kept current. See other side for additional information required for residential facilities for children. IDENTIFICATION AND EMERGENCY INFORMATION A. STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION This information is required under the H S Code and the regulations of the Department to be maintained on every person admitted to a community care facility to be readily available to the person in charge but not accessible to unauthorized persons. ALL FACILITIES EXCEPT CHILD CARE CENTER/FAMILY CHILD CARE HOME COMPLETES LIC 700 1. NAME OF CLIENT OR CHILD SOCIAL SECURITY NUMBER OPTIONAL 2. RESPONSIBLE PERSON OR PLACEMENT AGENCY DATE OF BIRTH AGE TELEPHONE ADDRESS 3. NAME OF NEAREST RELATIVE OPTIONAL RELATIONSHIP 4. DATE ADMITTED TO FACILITY ADDRESS PRIOR TO ADMISSION 5. DATE LEFT SEX FORWARDING ADDRESS 6. REASONS FOR LEAVING FACILITY PERSON S RESPONSIBLE FOR FINANCIAL AFFAIRS PAYMENT FOR CARE LEGAL GUARDIAN IF ANY NAME OTHER PERSONS TO BE NOTIFIED IN EMERGENCY a* b. DENTIST d. RELATIVE S e. MENTAL HEALTH PROVIDER IF ANY c* PHYSICIAN FRIEND S EMERGENCY HOSPITALIZATION PLAN NAME OF HOSPITAL TO BE TAKEN IN AN EMERGENCY ADDRESS OF HOSPITAL TO BE TAKEN IN AN EMERGENCY MEDICAL PLAN NAME OF DENTAL PLAN IF ANY DENTAL PLAN NUMBER IF ANY OTHER REQUIRED INFORMATION AMBULATORY STATUS RELIGIOUS PREFERENCE NAME AND ADDRESS OF CLERGYMAN OR RELIGIOUS ADVISOR IF ANY 11. CHILD S COURT STATUS ATTACH CUSTODY ORDERS AND AGREEMENTS WITH PARENT S OR PERSON S HAVING LEGAL CUSTODY. NOTE OPTIONAL FOR SMALL FAMILY AND FOSTER FAMILY HOMES PERSON S WITH WHOM CHILD HAS BEEN LIVING IF KNOWN NAME AND RELATIONSHIP VISITATION RESTRICTIONS BY COURT ORDER OR AUTHORIZED REPRESENTATIVE PERSON S NOT AUTHORIZED TO VISIT CHILD FAMILY RESIDENCE VISITATION RESTRICTIONS SPECIFY IF ANY ALL PERSONS AUTHORIZED TO REMOVE CHILD FROM HOME SPECIFY CONDITIONS TELEPHONE ACCESS IF NO SPECIFY RESTRICTIONS MAKE AND RECEIVE CONFIDENTIAL CALLS YES NO BY COURT ORDER. ALL FACILITIES EXCEPT CHILD CARE CENTER/FAMILY CHILD CARE HOME COMPLETES LIC 700 1. NAME OF CLIENT OR CHILD SOCIAL SECURITY NUMBER OPTIONAL 2. RESPONSIBLE PERSON OR PLACEMENT AGENCY DATE OF BIRTH AGE TELEPHONE ADDRESS 3. NAME OF NEAREST RELATIVE OPTIONAL RELATIONSHIP 4. RESPONSIBLE PERSON OR PLACEMENT AGENCY DATE OF BIRTH AGE TELEPHONE ADDRESS 3. NAME OF NEAREST RELATIVE OPTIONAL RELATIONSHIP 4. DATE ADMITTED TO FACILITY ADDRESS PRIOR TO ADMISSION 5. DATE LEFT SEX FORWARDING ADDRESS 6. REASONS FOR LEAVING FACILITY PERSON S RESPONSIBLE FOR FINANCIAL AFFAIRS PAYMENT FOR CARE LEGAL GUARDIAN IF ANY NAME OTHER PERSONS TO BE NOTIFIED IN EMERGENCY a* b. DATE ADMITTED TO FACILITY ADDRESS PRIOR TO ADMISSION 5. DATE LEFT SEX FORWARDING ADDRESS 6. REASONS FOR LEAVING FACILITY PERSON S RESPONSIBLE FOR FINANCIAL AFFAIRS PAYMENT FOR CARE LEGAL GUARDIAN IF ANY NAME OTHER PERSONS TO BE NOTIFIED IN EMERGENCY a* b. DENTIST d. RELATIVE S e. MENTAL HEALTH PROVIDER IF ANY c* PHYSICIAN FRIEND S EMERGENCY HOSPITALIZATION PLAN NAME OF HOSPITAL TO BE TAKEN IN AN EMERGENCY ADDRESS OF HOSPITAL TO BE TAKEN IN AN EMERGENCY MEDICAL PLAN NAME OF DENTAL PLAN IF ANY DENTAL PLAN NUMBER IF ANY OTHER REQUIRED INFORMATION AMBULATORY STATUS RELIGIOUS PREFERENCE NAME AND ADDRESS OF CLERGYMAN OR RELIGIOUS ADVISOR IF ANY 11. .