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, |
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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: |
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Have you ever been arrested for a crime against a child or for spousal |
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or cohabitant abuse? |
n YES |
n NO |
For Children’s Residential Facilities: |
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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: |
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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.