Mandatory California RCF Employee Forms
The required forms every Residential Care Facility (RCF/RCFE) employee must complete under California Department of Social Services (CDSS) Community Care Licensing Division regulations.
Background Check & Criminal Record Clearance
Required before an employee has any contact with residents. Submitted through CDSS Community Care Licensing.
- LIC 508
Criminal Record Statement
Signed by every applicant, employee, volunteer, and adult resident of the facility disclosing any criminal history.
- LIC 9163
Request for Live Scan Service — Community Care Licensing
CCL-specific Live Scan request used to initiate the DOJ/FBI fingerprint background check for facility staff.
- BCIA 8016
Request for Live Scan Service
California DOJ fingerprint clearance request — used when submitting Live Scan fingerprints for RCF/RCFE staff.
- LIC 9182
Criminal Background Clearance Transfer Request
Requests transfer of an existing CCLD criminal background clearance from a prior licensed facility.
Health Screening & TB Clearance
California Health & Safety Code requires health screening and TB testing prior to resident contact.
- LIC 503
Health Screening Report — Facility Personnel
Signed by a licensed physician documenting the employee's physical condition and TB clearance.
- LIC 9214
Application for Administrator Certification
Required for RCFE administrators to obtain and maintain California administrator certification.
Personnel Records & Employee Rights
Must be maintained in every RCF/RCFE personnel file and available for CCLD inspection.
- LIC 501
Personnel Record
Documents the employee's identification, education, references, and prior experience.
- LIC 500
Personnel Report
Overview of facility personnel including positions and duty hours.
- LIC 9052
Notice of Employee Rights
Provided to every CCLD-regulated employee describing their rights, including the right to file a complaint.
- LIC 9165
Board of Director Statement
Required for facilities operated by a corporate board — each director signs this CCLD statement.
Training, Reporting & Acknowledgements
Additional acknowledgements and reports required by California RCFE regulations (Title 22).
- SOC 341
Report of Suspected Dependent Adult/Elder Abuse
Mandated reporter form used to report suspected elder or dependent adult abuse to Adult Protective Services.
- SOC 341A
Mandated Reporter Statement — Elder/Dependent Adult Abuse
Signed acknowledgement confirming the employee has been trained as a mandated reporter.
- LIC 9227
Applicant/Employee Rights Notification (Background Check)
Explains the applicant's rights during the CCLD background check and exemption process.
- LIC 9106
Facility Personnel Report — RCFE
Documents each employee's date of hire, position, training hours, and CPR/First Aid certification.
Employee Handbook & Policy Booklet
Every Insightful Senior Services team member must read the Employee Handbook and complete the Employee Policy Booklet — initialing each policy and signing the acknowledgment page. Both PDFs are fully accessible (tagged headings, screen-reader friendly, searchable text, clickable table of contents, and a document outline / bookmark panel) and preview in every modern web browser.
- ISS-HB
Insightful Senior Services Employee Handbook
Fully tagged, accessible PDF with a clickable table of contents, document outline (bookmark panel), searchable text, and semantic headings for screen readers. Covers mission, employment relationship, dress code, attendance, client services, shadowing, HIPAA, safety, training, three-strike discipline, and the employee acknowledgment form.
Loading preview… - ISS-PB
Employee Policy Booklet — Read, Initial & Sign
Accessible companion to the handbook with a clickable table of contents, tagged headings, a line to initial next to each of 25 policies, and a final signature/acknowledgment page. Fully searchable and screen-reader friendly.
Loading preview…
All California form links open the official CDSS/DOJ PDF versions. Always confirm the most recent revision by visiting cdss.ca.gov/inforesources/forms-brochures.
Forms FAQ — Purpose, Latest Version & Required Fields
Quick reference for what each form is for, the current CDSS/DOJ revision, and the fields you must complete.
LIC 508 — Criminal Record Statement
Purpose: Self-disclosure of any prior criminal history before resident contact.
Version & required fields: Latest CDSS revision (rev. 12/20). Required fields: full legal name, date of birth, signature, date, and yes/no disclosure of prior convictions with dates and descriptions.
LIC 9163 — Live Scan (CCL)
Purpose: Initiates the DOJ/FBI fingerprint background check specifically for Community Care Licensing.
Version & required fields: Latest CDSS revision (rev. 10/22). Required fields: applicant identifying data, CCL 'Type of Application', facility name, facility number, and authorized applicant signature.
BCIA 8016 — Live Scan (DOJ)
Purpose: General California DOJ fingerprint clearance request used at the Live Scan appointment.
Version & required fields: Latest DOJ revision (rev. 11/20). Required fields: ORI number, authorized applicant type, billing information, and the operator/employee signature block.
LIC 9182 — Clearance Transfer Request
Purpose: Transfers an existing CCLD criminal background clearance from a prior licensed facility.
Version & required fields: Latest CDSS revision (rev. 6/19). Required fields: former facility number, applicant identifying data, and the new facility's authorized signature.
LIC 503 — Health Screening Report
Purpose: Documents physical fitness for duty and TB clearance before resident contact.
Version & required fields: Latest CDSS revision (rev. 6/17). Required fields: employee identification, physician exam results, TB test method and date, and licensed physician signature.
LIC 9214 — Administrator Certification
Purpose: Application for the RCFE Administrator certification required to operate a facility.
Version & required fields: Latest CDSS revision (rev. 7/22). Required fields: applicant biographical data, education/experience, completion of the 80-hour certification course, and payment of the application fee.
LIC 501 — Personnel Record
Purpose: Master personnel file entry for every RCF/RCFE employee.
Version & required fields: Latest CDSS revision (rev. 9/08). Required fields: identification, prior employment, education, references, and the employee's date of hire and position.
LIC 500 — Personnel Report
Purpose: Facility-wide roster identifying every employee and their duty hours.
Version & required fields: Latest CDSS revision (rev. 9/08). Required fields: employee name, position, hours per week, and date of hire; updated whenever staffing changes.
LIC 9052 — Notice of Employee Rights
Purpose: Notifies each CCLD-regulated employee of their statutory rights and complaint options.
Version & required fields: Latest CDSS revision (rev. 8/17). Required fields: employee signature and date acknowledging receipt; the facility retains the signed copy on file.
LIC 9165 — Board of Director Statement
Purpose: Signed statement from each director of a corporate operator, disclosing background information.
Version & required fields: Latest CDSS revision (rev. 1/17). Required fields: director's identifying data, corporate role, criminal history disclosure, and notarized-quality signature.
SOC 341 — Suspected Abuse Report
Purpose: Mandated reporter report of suspected elder or dependent adult abuse to APS.
Version & required fields: Latest CDSS revision (rev. 6/22). Required fields: reporter identification, victim identification, incident description, and immediate submission to APS/local law enforcement.
SOC 341A — Mandated Reporter Acknowledgement
Purpose: Employee acknowledgement of mandated-reporter training and obligations.
Version & required fields: Latest CDSS revision (rev. 6/22). Required fields: employee signature, date, and confirmation of completed mandated-reporter training.
LIC 9227 — Applicant Rights Notification
Purpose: Explains applicant rights during the CCLD background check and exemption process.
Version & required fields: Latest CDSS revision (rev. 1/20). Required fields: applicant signature and date acknowledging receipt of the rights notice.
LIC 9106 — Facility Personnel Report (RCFE)
Purpose: Tracks employee training hours, CPR/First Aid status, and dates of hire specifically for RCFEs.
Version & required fields: Latest CDSS revision (rev. 5/19). Required fields: employee name, position, hire date, cumulative training hours, and CPR/First Aid certification dates.
Compliance Disclaimer & How to Use These Forms
The documents above are the mandatory forms required of Residential Care Facility (RCF/RCFE) personnel under California Health & Safety Code Division 2, Chapter 3.2 and Title 22, California Code of Regulations. They are published by the California Department of Social Services (CDSS) Community Care Licensing Division (CCLD) and the California Department of Justice (DOJ).
How employees should use these forms:
- Download each applicable form, complete it in blue or black ink (or fillable PDF), and sign where indicated.
- Do not begin any resident contact until your Criminal Record Statement (LIC 508), Live Scan (LIC 9163 / BCIA 8016), Health Screening (LIC 503), and TB clearance are on file.
- Return completed forms directly to the Insightful Senior Services services coordinator by secure email or in person — never leave them with residents or unauthorized staff.
- Keep a personal copy of every form you sign for your own records.
- Report any change in criminal history, health status, or certification immediately, per Title 22 §87355 and §87411.
Confirm the latest version:
- CDSS Forms & Brochures index — cdss.ca.gov/inforesources/forms-brochures
- CDSS Community Care Licensing Division — cdss.ca.gov/inforesources/community-care-licensing
- California DOJ Applicant Live Scan Program — oag.ca.gov/fingerprints
Insightful Senior Services provides these links as a convenience. We are not the publisher of these forms and are not responsible for changes made by CDSS or DOJ. This page is informational and does not constitute legal or regulatory advice.
Submit Your Completed Forms
Return completed forms by email to info@insightfulseniorservices.org or call our office at (951) 296-8869 to arrange in-person drop-off.