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The LIC 508 form serves a critical role in the safeguarding of vulnerable populations within licensed care facilities in California. Designed by the Health and Human Services Agency’s California Department of Social Services, it is integral for applicants associated with various caregiving roles, including those seeking positions in the Home Care Aide Registry or TrustLine Registry. This form mandates the disclosure of criminal convictions, encompassing any guilty pleas or verdicts, while allowing certain exemptions for marijuana-related offenses under recent legislation. Individuals must also report any criminal history from other states, as well as details of any arrests related to child abuse or domestic violence, particularly for those applying to foster family homes or children's residential facilities. The form's requirements extend beyond mere disclosure; applicants must be aware that failing to report any convictions accurately could lead to severe consequences, including application denials or revocation of licenses. Additionally, the form emphasizes the importance of maintaining updated personal information with the Caregiver Background Check Bureau, reminding applicants to ensure their records are current within a strict timeline of ten days following any changes.

Lic 508 Example

State of California ­– Health and Human Services Agency

California Department of Social Services

CRIMINAL RECORD STATEMENT & OUT-OF-STATE DISCLOSURE

State law requires that persons associated with licensed care facilities, Home Care Aide Registry or TrustLine Registry applicants be fingerprinted and disclose any conviction. A conviction is any plea of guilty or nolo contendere (no contest) or a verdict of guilty. The fingerprints will be used to obtain a copy of any criminal history you may have.

Have you ever been convicted of a crime in California?

n YES n NO

You do not need to disclose any marijuana-related offenses covered by the marijuana reform legislation codified at Health and Safety Code sections 11361.5 and 11361.7.

Have you ever been convicted of a crime from another state, federal court,

 

military, or jurisdiction outside of U.S.?

n YES n NO

You do not need to disclose convictions that were a result of one’s status as a victim of human trafficking and that were dismissed pursuant to Penal Code Section 1203.49, nor any marijuana-related offenses covered by the marijuana reform legislation codified at Health and Safety Code sections 11361.5 and 11361.7. However, you are required to disclose convictions that were dismissed pursuant to Penal Code Section 1203.4(a).

Criminal convictions from another State or Federal court are considered the same as criminal convictions in California.

For Foster Family Homes, Certified Family Homes, and Resource Families only:

 

 

Have you ever been arrested for a crime against a child or for spousal

 

 

or cohabitant abuse?

n YES

n NO

For Children’s Residential Facilities:

 

 

Have you lived in a state other than California within the last five years?

n YES

n NO

If yes, list each state below and then complete an LIC 198B for each state:

 

 

________________________________________________________________________________

________________________________________________________________________________

You must check yes to the corresponding question(s) above to report every conviction (including reckless and drunk driving convictions) you have on your record, even if:

It happened a long time ago;

It was only a misdemeanor;

You didn’t have to go to court (your attorney went for you);

You had no jail time, or the sentence was only a fine or probation;

You received a certificate of rehabilitation; or

The conviction was later dismissed, set aside or the sentence was suspended.

NOTE: IF THE CRIMINAL BACKGROUND CHECK REVEALS ANY CONVICTION(S) THAT YOU DID NOT REPORT ON THIS FORM BY CHECKING YES, YOUR FAILURE TO DISCLOSE THE CONVICTION(S) MAY RESULT IN AN EXEMPTION DENIAL, APPLICATION DENIAL, LICENSE REVOCATION, DECERTIFICATION, RESCISSION OF APPROVAL, OR EXCLUSION FROM A LICENSED FACILITY, CERTIFIED FAMILY HOME, OR THE HOME OF A RESOURCE FAMILY.

LIC 508 (7/20)

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State of California ­– Health and Human Services Agency

California Department of Social Services

 

 

 

 

If you move or change your mailing address, you must send your updated information to the Caregiver Background Check Bureau within 10 days to:

Caregiver Background Check Bureau

744 P Street, M/S T9-15-62

Sacramento, CA 95814

I declare under penalty of perjury under the laws of the State of California that I have read and understand the information contained in this affidavit and that my responses and any accompanying attachments are true and correct.

FACILITY/ORGANIZATION/AGENCY NAME:

FACILITY/ORGANIZATION NUMBER:

YOUR NAME (print clearly):

YOUR ADDRESS (street, city, state, zip):

SOCIAL SECURITY NUMBER: (See Privacy Statement on Page 3):

DRIVER’S LICENSE NUMBER/STATE:

DATE OF BIRTH:

SIGNATURE:

DATE:

Instructions to Licensees:

If the person discloses that they have ever been convicted of a crime, maintain this form in your facility/organization personnel file and send a copy to your Licensed Program Analyst (LPA) or assigned analyst.

Instructions to Regional Offices and Foster Family Agencies:

If ‘Yes’ is indicated in any box above, forward a copy of this completed form (and the LIC 198B, as applicable) to the Caregiver Background Check Bureau, 744 P Street, MS T9-15-62, Sacramento, CA 95814.

If ‘No’ is indicated above in all boxes, keep this completed form in the facility file.

LIC 508 (7/20)

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State of California ­– Health and Human Services Agency

California Department of Social Services

 

 

 

 

PRIVACY STATEMENT

Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code section 1798 et seq.), notice is given for the request of the Social Security Number (SSN) on this form. The California Department of Justice uses a person’s SSN as an identifying number. The requested SSN is voluntary. Failure to provide the SSN may delay the processing of this form and the criminal record check.

In order to be licensed, work at, or be present at a licensed facility/organization, the law requires that you complete a criminal background check. (Health and Safety Code sections 1522, 1568.09, 1569.17, 1596.871, and 1796.19). The Department will create a file concerning your criminal background check that will contain certain documents, including information that you provide. You have the right to access certain records containing your personal information maintained by the Department (Civil Code section 1798 et seq.). Under the California Public Records Act, the Department may have to provide copies of some of the records in the file to members of the public who ask for them, including newspaper and television reporters.

NOTE: IMPORTANT INFORMATION

With the exception of Foster Family Homes, Certified Family Homes, Small Family Childcare Homes, and Resource Family Approval Homes, the Department is required to tell people who ask, including the press, if someone in a licensed facility/organization has a criminal record exemption. The Department must also tell people who ask, the name of a licensed facility/organization that has a licensee, employee, resident, or other person with a criminal record exemption.

If you have any questions about this form, please contact your local licensing regional office.

LIC 508 (7/20)

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File Breakdown

Fact Name Details
Purpose of LIC 508 The LIC 508 form is used to disclose any criminal history as part of the application process for individuals associated with licensed care facilities in California.
Conviction Disclosures Applicants must disclose any criminal convictions, including those from other states, unless they are marijuana-related offenses or certain dismissals.
Governing Laws This form operates under California Health and Safety Code sections 1522, 1568.09, 1569.17, 1596.871, and 1796.19.
Consequences of Non-disclosure Failure to disclose convictions on the form may lead to denial of exemptions, applications, and possible revocation of licenses.
Address Update Requirement If an applicant moves, they are required to update the Caregiver Background Check Bureau within 10 days of the change.

Guide to Using Lic 508

Completing the LIC 508 form accurately is critical for your application process. Ensure all information is correct to avoid complications that could result in denial or revocation of your license. Follow the instructions below carefully.

  1. Begin by downloading the LIC 508 form from the California Department of Social Services website.
  2. Fill in the facility, organization, or agency name at the top of the form.
  3. Enter the facility or organization number in the designated space.
  4. Print your name clearly in the "YOUR NAME" section.
  5. Provide your complete address including street, city, state, and zip code.
  6. Include your Social Security Number in the appropriate field. Remember that providing this is voluntary.
  7. Record your driver’s license number and the state that issued it.
  8. Add your date of birth in the specified format.
  9. Carefully read through the questions regarding prior convictions. Answer each question truthfully. Select 'YES' or 'NO' as appropriate.
  10. If you answer 'YES' to any questions regarding convictions, ensure that you report every conviction in the designated area.
  11. For questions related to having lived outside California, list each state where you lived in the past five years, if applicable, and complete a LIC 198B for each state.
  12. Sign and date the form at the bottom, affirming that your responses are accurate and complete.

After completing the form, retain a copy for your records. If you acknowledged any convictions, maintain this in your personnel file. If applicable, forward a copy to the Caregiver Background Check Bureau, along with any necessary additional documentation. Ensure you send it to the provided address promptly.

Get Answers on Lic 508

What is the purpose of the LIC 508 form?

The LIC 508 form serves as a Criminal Record Statement and Out-of-State Disclosure required by California law. Individuals associated with licensed care facilities, including Home Care Aide Registry and TrustLine Registry applicants, must complete this form. It collects information about any criminal convictions, allowing authorities to conduct background checks to ensure the suitability of individuals in caregiving positions.

Who is required to complete the LIC 508 form?

Persons applying for positions associated with licensed care facilities must complete the LIC 508 form. This includes applicants for Home Care Aide Registry and TrustLine Registry. It is essential for ensuring the safety and welfare of individuals receiving care. Additionally, the form must be completed by anyone associated with Foster Family Homes, Certified Family Homes, and others required to disclose criminal history.

What types of criminal convictions must be reported?

All criminal convictions must be reported, including misdemeanors and felonies. This includes any plea of guilty or no contest as well as verdicts of guilty. Specific exemptions apply, such as marijuana-related offenses covered by certain legislative reforms and convictions dismissed under Penal Code Section 1203.49. However, convictions dismissed under Penal Code Section 1203.4(a) must be disclosed.

What are the consequences of failing to disclose a conviction?

Not disclosing a conviction can lead to serious consequences. If a background check reveals any undisclosed convictions, it may result in denial of an exemption, application denial, revocation of licenses, or exclusion from involvement in a licensed facility. The law mandates full transparency to protect individuals in caregiving environments.

What should individuals do if their mailing address changes?

If an individual’s mailing address changes, they must notify the Caregiver Background Check Bureau within 10 days. This ensures that all correspondence is up-to-date and that the individual remains compliant with licensing requirements. Notifications must be sent to the designated address in Sacramento, California.

Common mistakes

Filling out the LIC 508 form can be straightforward, but there are some common mistakes that people often make. One frequent error is failing to disclose all required convictions. Even if a conviction occurred many years ago or was only a misdemeanor, it must still be reported. Ignoring this requirement can result in serious consequences, including denial of your application or revocation of your license.

Another mistake is forgetting to answer all questions accurately. People sometimes overlook sections about crimes committed in other states or jurisdictions. It's essential to remember that convictions from outside California are treated the same as those within the state. Not checking “Yes” where appropriate can lead to complications in the approval process.

Some individuals misinterpret the exemptions listed. For instance, while marijuana-related offenses covered by specific reform legislation do not need to be disclosed, it is crucial to understand which convictions still must be reported. Confusing these details can jeopardize your application.

Proper documentation is also important. When you move or change your mailing address, you must notify the Caregiver Background Check Bureau within ten days. Failure to update your address may cause delays in processing your application or important communications.

A common oversight is not providing a complete name or address. Ensuring that your information is clear and complete is vital. Ambiguities can lead to misunderstandings and delays. Writing your name and address legibly prevents complications.

Additionally, not signing the form or forgetting to include the date can render your application invalid. A signature is a crucial part of the verification process. Always double-check to ensure your signature is present and that you have dated the form correctly.

Some people also neglect to read the entire form thoroughly. Each section contains essential information that may be applicable to your specific situation. Thorough reading helps in understanding your obligations and the potential implications of your answers.

Finally, many applicants do not retain a copy of the completed form. Keeping a copy for your records can provide a useful reference and help track any inconsistencies or issues that may arise later on. It creates a clear account of what information you provided, making it easier to address any concerns that may come up.

Documents used along the form

When submitting your Lic 508 form, you may also need to complete several other important documents. Each of these forms plays a significant role in the licensing process and helps ensure a safe environment for everyone involved. Here’s a brief overview of some forms often used alongside the Lic 508:

  • LIC 198B: This form is used for disclosing any out-of-state criminal history. If you have lived outside California in the last five years, it may be necessary to fill out this document to report any relevant convictions from those states.
  • LIC 9088: The application for a license to operate a care facility. This includes comprehensive information about the facility and its operational plans, ensuring compliance with state regulations.
  • LIC 600A: This document serves as the application for a foster family agency license. It outlines important details regarding the management and standards of care for foster homes.
  • LIC 995: This form relates to the facility's emergency preparedness plan. It must detail how staff will handle various emergencies, ensuring the safety of all individuals in care.
  • LIC 509: This is the verification of the criminal background check process. It provides confirmation that the necessary background checks have been completed, allowing for compliance with state regulations.

In conclusion, completing the Lic 508 form often involves additional documentation to ensure thorough vetting and compliance with legal requirements. Each form contributes to a safe and supportive environment, prioritizing the wellbeing of clients and staff alike. Staying informed about these documents will help you navigate the process with confidence.

Similar forms

The Lic 508 form, required by the State of California for criminal record disclosure, shows similarities to several other important legal documents. Below is a description of five similar forms and how they relate to the Lic 508.

  • LIC 198B - Out-of-State Disclosure Form: Just like the Lic 508, this form requires individuals to disclose any criminal history, specifically focusing on offenses from states outside California. Both forms emphasize the necessity of transparency regarding convictions to protect vulnerable populations.
  • Live Scan Request Form: Similar to the Lic 508, the Live Scan form is used to initiate a criminal background check through fingerprinting. Both documents require identifying information and are pivotal in ensuring the safety of individuals in care facilities.
  • Application for Family Child Care Home License: When applying for a family child care license, applicants must also disclose any criminal convictions. This form, like the Lic 508, plays a crucial role in safeguarding children and vulnerable adults by evaluating an applicant's criminal history.
  • Child Abuse Central Index (CACI) Clearance Request: This form, similar to the Lic 508, mandates applicants to provide information about their criminal background, specifically focusing on any cases related to child abuse. Both ensure a rigorous screening process to protect children from potential harm.
  • Department of Justice (DOJ) Request for Criminal Records: This document is akin to the Lic 508 in that it requests individuals to disclose any past criminal records. The importance of this form lies in its role of conducting thorough background checks, essential for those entering sensitive positions that require a high degree of trust.

Each of these documents, like the Lic 508, is designed to promote safety and trust, ensuring that individuals involved in caregiving roles are subject to comprehensive background checks. Understanding their similarities highlights the ongoing commitment to accountability in care services.

Dos and Don'ts

When filling out the Lic 508 form, keep these important do's and don'ts in mind:

  • Do provide accurate and truthful responses about your criminal history.
  • Do disclose any convictions, including misdemeanors or those that occurred a long time ago.
  • Do list any states where you have lived in the last five years if applicable.
  • Do check "yes" for any arrest or conviction related to child abuse or domestic violence.
  • Do inform the Caregiver Background Check Bureau of any address changes within 10 days.
  • Don't omit any criminal convictions, regardless of the circumstances surrounding them.
  • Don't forget to sign and date the form when completing it.
  • Don't provide false information; it can lead to severe consequences like application denial or license revocation.
  • Don't assume that being a victim of human trafficking exempts all convictions from disclosure.

Misconceptions

Misconceptions surrounding the Lic 508 form often lead to confusion. Below are some common myths along with clarifications:

  • Misconception 1: Only serious crimes need to be reported.
  • All convictions must be disclosed, even if they are minor misdemeanors or occurred a long time ago.

  • Misconception 2: Marijuana-related offenses do not need to be disclosed.
  • This is true only for offenses covered under specific legislation. Other marijuana-related convictions must be reported.

  • Misconception 3: If you weren’t convicted in California, you don’t need to report it.
  • Convictions from other states or federal courts must be treated the same as California convictions and reported accordingly.

  • Misconception 4: You can avoid reporting if an attorney handled your case.
  • It does not matter if you went to court yourself or if an attorney represented you; any conviction must be reported.

  • Misconception 5: If a conviction was dismissed, it doesn’t need to be reported.
  • Convictions dismissed under Penal Code Section 1203.4(a) must still be disclosed.

  • Misconception 6: Updating your address on the form is optional.
  • If you move, it is mandatory to notify the Caregiver Background Check Bureau within 10 days.

  • Misconception 7: Fingerprints are not necessary if you have no convictions.
  • Fingerprints are a requirement for everyone involved with licensed care facilities, regardless of their criminal history.

  • Misconception 8: If there are no boxes checked, the form isn't necessary.
  • Even if all answers are 'No,' the form must still be completed and kept on file.

  • Misconception 9: The license can’t be revoked for failures in reporting.
  • Omissions or inaccuracies in disclosing convictions can lead to serious consequences, including denial or revocation of a license.

Key takeaways

Filling out the LIC 508 form is a critical step for individuals associated with licensed care facilities. Ensure that you answer all questions honestly, as any undisclosed criminal convictions may lead to serious consequences, including application denial or revocation of your license.

  • The form requires disclosure of all criminal convictions, even those that might seem minor.
  • Crimes committed in other states or jurisdictions must be reported just as if they occurred in California.
  • Even if a conviction has been dismissed or you received a certificate of rehabilitation, you must still disclose it if applicable under the law.
  • Updating your address with the Caregiver Background Check Bureau is vital—failure to do so within 10 days can affect your application status.

Accurate completion of this form is essential for ensuring the safety and well-being of those in care facilities. Be thorough and attentive to detail as you fill it out.