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The Lic 279 form is an essential document for individuals seeking to operate a Family Child Care Home in California. This application is designed for various scenarios, including new licensing requests, capacity changes, or changes in location. It requires detailed personal information and confirmation that the applicants live in the home where care will be provided. The form asks for the applicants' home address, any previous county residences, and a contact phone number. In addition to personal details, it also seeks to gather information about other adults living in the household and the children currently residing in the home. The applicants must specify the type of license they are applying for and the ages of children they intend to serve. Responsibilities, such as ensuring compliance with fire safety regulations and reporting any known or suspected child abuse, are thoroughly outlined within the application. Each applicant is required to affirm the accuracy of the information provided and sign a statement under penalty of perjury, ensuring that all declarations are truthful. Filling out the Lic 279 form correctly is crucial for obtaining the appropriate license and providing a safe environment for children in care.

Lic 279 Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING

APPLICATION FOR A FAMILY CHILD CARE HOME LICENSE

Type or print clearly.

1.

TYPE OF APPLICATION

 

 

New Application Capacity Change Location Change

Update

AGENCY USE ONLY

NUMBER:

TYPE:

ASSIGN:

2.

APPLICANT(S) First

 

 

Middle

 

Last Name

 

Over 18 Years Old?

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

3a.

YOUR HOME ADDRESS:

CITY

COUNTY

STATE

ZIP

PHONE:

 

 

 

 

 

 

 

 

 

 

 

3b. IF YOU HAVE NOT LIVED IN THIS COUNTY FOR THE PAST TWO YEARS, LIST THE COUNTIES IN WHICH YOU HAVE RESIDED:

4. MAILING ADDRESS (if different):

CITY

STATE

ZIP

EMAIL ADDRESS (NOT REQUIRED)

5.

DIRECTION(S) TO HOME:

6.ARE YOU CURRENTLY, OR HAVE YOU EVER BEEN, LICENSED OR CERTIFIED FOR ANY TYPE OF FACILITY TO CARE FOR CHILDREN OR ADULTS?

Yes No Pending

DATE LICENSED/CERTIFIED:

PHONE:

ADDRESS:

 

 

CITY

 

STATE

ZIP

 

 

 

 

 

 

 

TYPE OF LICENSE:

LICENSE #:

 

LICENSING AGENCY:

 

 

 

 

 

 

 

 

7.

OTHER ADULTS IN THE HOME (Not applicant(s)) Do not list the names of persons under 18 years of age

 

 

First Name

Middle

 

Last Name

 

Relationship to You

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

CURRENT CHILDREN IN YOUR HOME (LIC 279B) Click to access

 

 

 

 

 

9.

TYPE OF LICENSE

 

 

 

AGES TO BE SERVED:

 

DAYS & HOURS OPEN:

 

 

 

 

 

 

 

 

Small Home (up to 8)

Large Home (up to 14)

 

 

 

 

 

10.APPLICANT/LICENSEE RESPONSIBILITY - I/We certify that:

A.I/We live in the home to be licensed.

B.I/We have money to maintain the level of service required by law in a Family Child Care Home.

C.I/We have both a State Fire Marshal approved fire extinguisher (rated 2A, 10B: C) and a smoke detector in operating condition.

D.I/We shall stay current and in compliance with the laws and regulations governing standards for Family Child CareHomes.

E.I/We shall obtain approval from the licensing agency before making changes in our license capacity, or to our home.

F.I/We shall notify the licensing agency when we want to discontinue our license.

G.I/We have informed the property owner, if leased or rented, that we will be operating a Family Child Care Home on the premises. The owner/landlord has been sent the Property Owner/Landlord Notification (LIC 9151).

H.I/We have written consent from the property owner, if leased or rented, when I plan to expand my Small Family Child Care Home capacity from 6 to 8 children, or to expand my Large Family Child Care Home capacity from 12 to 14 children. Property Owner/Landlord Consent Form (LIC 9149).

I.I/We understand the requirements to report known or suspected child abuse (LIC 9108).

11.PERJURY STATEMENT - I/We declare under penalty of perjury that the statements on this application and accompanying attachments are correct to the best of my/our knowledge.

Applicant(s) Signatures

City and County where Signed

Date

Did you remember to: Sign and date all documents in ink and enclose the application/licensing fee?

LIC 279 (2/09)

PAGE 1 OF 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

Need Help Completing The

Application For a Family Child Care Home License?

These are instructions for filling out the Application for a Family Child Care Home License (LIC 279). Match the numbered items on this page with the numbered sections on the Application.

For your information, details on the Application are public information.

1.TYPE APPLICATION - A “New Application” is a request to license both an individual and a home that are not now licensed. A “Capacity Change” is a request to increase the approved number of children in an already licensed home. A “Location Change” is a request by a licensee to obtain a new license when he/she plans to move. An “Update” is, for example, to request a change in your name or phone number.

2.APPLICANTS - The applicants are the persons who will be responsible for providing child care in their own home. All applicants must live in the home to be licensed and must be 18 years of age or older to be licensed to provide child care. A “Yes” check means the applicants are 18 years of age or older.

3a. YOUR HOME ADDRESS - Your home address is the location of the home in which you live and want to provide care. This is the home that the Licensing Agency will inspect to determine whether it meets health and safety standards. PHONE NUMBER--Enter your primary phone number.

3b. LIST OF ADDITIONAL COUNTIES - If you have not lived in this county for two years, list all other counties where you have lived in the past two years.

4.MAILING ADDRESS - If your mailing address is different from the home address, put your mailing address here. If it is the same, write "Same". EMAIL ADDRESS--It is not a required field to complete.

5.DIRECTION(S) TO HOME - Please provide directions to your home. Please attach a sketch or map if possible.

6.LICENSE OR CERTIFICATION STATUS - This is any license or certification issued to any of the applicants for providing care. If you are or have ever been licensed or certified to provide care, or if an application is pending, check the appropriate box and enter the type of license/certification; date licensed/certified; and name, address and phone number of the Licensing Agency. This includes Foster Family Homes and any other license category.

7.OTHER ADULTS IN THE HOME - List all persons (other than yourself) who live in your home, including family members, boarders, or other relatives. Do not list the names of persons under 18 years of age (See #8 below). If needed, you may attach additional pages to list all residents. You do not need to list your spouse if he/she is also an applicant.

8.CURRENT CHILDREN IN YOUR HOME - Complete the form LIC 279B. List the name, date of birth, sex and relationship of each child living in your home. This sheet will be filed in the confidential portion of your facility file.

9.TYPE OF LICENSE - Requirements for homes serving nine or more children are different from homes serving eight or fewer. Please tell us the capacity you plan to serve, the age range, and what days and/or hours you plan to be open.

10.APPLICANT/LICENSEE RESPONSIBILITY - You need to let the Licensing Agency know that you live in the home to be licensed, have enough money to maintain your home, have basic fire protection, will stay current and in compliance with licensing laws and regulations, will obtain approval from the licensing agency whenever you plan to change your license capacity or make changes to your home, and that you understand the child abuse reporting requirements and the notification and consent requirements related to property owners/landlords.

11.PERJURY STATEMENT - Each applicant must sign the application. The signatures should be the same as the names listed on the top of the form. The signature is signed under a perjury oath. This means that you promise that everything you have said in the application is true and correct. If you knowingly make false statements, you have committed the crime of perjury, which may be punishable by imprisonment.

NOTE: IF YOU DO NOT HAVE ENOUGH SPACE, ATTACH ADDITIONAL PAPER.

LIC 279 (2/09)

PAGE 2 OF 2

Form Characteristics

Fact Name Description
Application Types The LIC 279 form is used for several types of applications, including New Applications, Capacity Changes, Location Changes, and Updates.
Age Requirement All applicants must be at least 18 years old and must live in the home they seek to license.
Licensing Agency This application is governed by California law under the Department of Social Services, specifically targeting family child care home licenses.
Perjury Statement Applicants must sign a declaration under penalty of perjury, affirming the truthfulness of all provided information on the form.

Guidelines on Utilizing Lic 279

Properly completing the Lic 279 form is essential for obtaining a Family Child Care Home License in California. This form requires clear and accurate information about the applicants and the home where care will be provided. Failure to fill it out correctly may delay the licensing process.

  1. Type of Application: Indicate whether you are applying as a "New Application," "Capacity Change," "Location Change," or "Update." Check the appropriate box.
  2. Applicant Information: List the first, middle, and last names of all applicants. Confirm that each applicant is over 18 by checking "Yes" or "No." Ensure all names are correct.
  3. Your Home Address: Fill in your home address, including the city, county, state, and ZIP code. Also, provide your phone number.
  4. Previous Residences: If you have lived in the current county for less than two years, list all other counties where you have resided.
  5. Mailing Address: If different from your home address, provide your mailing address. If it’s the same, simply write "Same." You may include an email address, but it’s not mandatory.
  6. Directions to Home: Offer clear directions to your home. If helpful, attach a sketch or map.
  7. License or Certification Status: Indicate if you or any applicant is currently or has previously been licensed. Specify the type of license/certification, date, and the details of the licensing agency.
  8. Other Adults in the Home: List all adults living in your home, excluding those under 18 and your spouse if they are also an applicant.
  9. Current Children in Your Home: Complete the LIC 279B form to list all children living in your home, detailing their names, dates of birth, sexes, and relationships.
  10. Type of License: Choose between a "Small Home" for up to 8 children or a "Large Home" for up to 14 children. Specify the ages of the children you will serve and your operational days and hours.
  11. Applicant/Licensee Responsibility: Read this section carefully. By checking the applicable boxes, certify your responsibilities regarding living conditions, financial stability, safety equipment, and compliance with laws.
  12. Perjury Statement: Each applicant must sign and date the application in ink. Ensure signatures match the names provided at the top of the form.

Remember to review the entire form for completeness and accuracy before submission. Failing to sign or date any section may lead to delays. The completed form must be submitted along with the required licensing fee. Ensure you keep a copy for your records. Seek assistance if needed, as guidance is available for this process.

What You Should Know About This Form

What is the Lic 279 form used for?

The Lic 279 form, or the Community Care Licensing Application for a Family Child Care Home License, is used by individuals seeking to provide child care in their own homes in California. This application is essential for both new applicants and those looking to make changes to their current licensing status, such as increasing capacity or relocating. By completing this form, applicants initiate the licensing process, which includes ensuring the home meets safety regulations and health standards.

Who can apply for a Family Child Care Home License?

Typically, anyone over the age of 18 who wishes to provide child care in their home can apply for this license. All applicants must reside in the home to be licensed. This requirement ensures that the individuals responsible for child care are present on the premises and able to fulfill their caregiving responsibilities effectively. If the applicant lives with other adults, there is space on the form to list those individuals, which helps the licensing agency understand who will be living in the home.

What are the different types of applications available on the Lic 279 form?

The form offers several application types to cater to various needs. A "New Application" is for those not previously licensed. If you currently hold a license but wish to increase the number of children you can care for, you would select "Capacity Change." Additionally, if you intend to move your child care service to a new location, the "Location Change" option should be chosen. Lastly, an "Update" is used for making minor modifications, such as changing contact details or the applicant's name.

What responsibilities do applicants have after submitting the Lic 279 form?

Upon submitting the form, applicants take on several responsibilities. They must confirm that they live in the licensed home and have the financial resources necessary to maintain the required standards. The applicants are also accountable for ensuring basic safety measures are in place, such as a functioning fire extinguisher and smoke detectors. It is crucial for them to remain compliant with legal requirements governing Family Child Care Homes and to notify the licensing agency of any changes that might affect their license.

What happens if the information provided on the Lic 279 form is found to be false?

Every applicant must sign the Lic 279 form under a perjury statement. This means that by signing, they are declaring that all statements made are true and accurate. If an applicant is found to have provided false information, they may face serious consequences, including criminal charges for perjury. Such repercussions could lead to imprisonment, highlighting the importance of honesty and accuracy throughout the application process.

Common mistakes

When filling out the Lic 279 form, individuals commonly make several mistakes that can impact the processing of their application. One frequent error is failing to check the correct type of application. It is essential to indicate whether it is a new application, a capacity change, a location change, or an update. Not selecting the appropriate option may lead to confusion and delays in the review process.

Another common mistake involves the applicant's information. Applicants sometimes forget to indicate whether they are over 18 years old. This detail is crucial, as all applicants must be of legal age. Leaving this section blank or answering incorrectly can result in the application being returned.

Providing an incomplete home address is also an issue. Some individuals may skip important details, such as the ZIP code or phone number. This information is necessary for communication and for the licensing agency to conduct any required inspections. Ensuring accuracy in the home address helps avoid complications later on.

Listing additional counties of residence can be overlooked, especially if people have not lived in the current county for the past two years. It is important to include all relevant counties where the applicant has resided to provide complete information to the licensing agency.

Individuals may also neglect to list all other adults living in the home. This includes anyone who may be present, such as relatives or boarders. Omitting this information can lead to misunderstandings about who will be living in the licensed home.

Another mistake occurs in parts of the application that verify the applicant's licensing or certification history. Applicants often forget to provide complete details if they have been licensed or certified previously. It is important to include any licenses or certifications, as this information affects the application status.

Completing the child information section can be another area of confusion. Some people might not realize that the form LIC 279B is necessary to list the current children in the home. This section is vital, and failing to submit it can result in incomplete records.

Lastly, neglecting to sign and date the form correctly can lead to significant delays. Each applicant must provide an ink signature that matches the names listed. Incomplete signatures can result in the application being considered invalid. Taking the time to review and ensure every part is complete can help streamline the process.

Documents used along the form

When applying for a Family Child Care Home License in California, several other forms and documents may accompany the Lic 279 form. Each document serves a specific purpose that aids the licensing process and ensures compliance with state regulations. Here’s a concise overview of seven common accompanying documents you might encounter.

  • Lic 279B - Current Children in Your Home: This form lists the names, dates of birth, and relationships of all children residing in the home, providing critical information for the licensing authority.
  • Lic 9151 - Property Owner/Landlord Notification: This notification confirms that the property owner has been informed about the intent to operate a Family Child Care Home on the premises, ensuring transparency in the landlord-tenant relationship.
  • Lic 9149 - Property Owner/Landlord Consent Form: If there are plans to increase the capacity of the facility, this form documents the property owner's written consent for such an expansion.
  • Lic 9108 - Child Abuse Reporting Requirements: This form provides information on the legal obligations regarding reporting known or suspected child abuse, ensuring caregivers understand their responsibilities.
  • Community Care Licensing (CCL) Background Check: A background check is typically required to assess the suitability of individuals involved in the care of children, highlighting the agency’s commitment to child safety.
  • Proof of Fire Safety Compliance: Documentation demonstrating compliance with fire safety regulations, such as having a state-approved fire extinguisher and smoke detectors installed, is crucial for certification.
  • Health and Safety Training Certificates: These documents verify that all applicants have completed necessary training in health and safety practices, fostering a safe environment for children.

Each of these forms and documents plays a vital role in the licensing process, helping to establish a framework of safety and compliance for Family Child Care Homes. By ensuring that all required documents are completed and submitted, applicants increase their chances of successfully obtaining their childcare license while promoting a safe and nurturing environment for children.

Similar forms

  • LIC 9151 - Property Owner/Landlord Notification: This form is similar to the LIC 279 as it requires the property owner to be informed about the operation of a Family Child Care Home. It ensures that the owner is aware and provides necessary consent, just like the LIC 279 addresses consent requirements for property owners.

  • LIC 9149 - Property Owner/Landlord Consent Form: This document is used to obtain written consent from the property owner when expanding the capacity of a Family Child Care Home. It parallels the LIC 279's requirement for notifying the landlord about the intended care facility operations.

  • LIC 9108 - Child Abuse Reporting requirements: The LIC 279 contains a section emphasizing the importance of understanding child abuse reporting obligations, similar to the LIC 9108 form, which provides specific protocols for reporting suspected abuse.

  • LIC 279B - Current Children in Your Home: This supplemental form requires the listing of all children living in the home, akin to how the LIC 279 asks about the applicant's household structure, including current children.

  • LIC 809 - Facility Evaluation Report: After submitting the LIC 279, an evaluation report is conducted to inspect the facility. Both documents aim to ensure that the care environment meets established legal and safety standards.

  • LIC 200 - Application for a License: This general application form for various facilities shares the purpose of sourcing essential applicant information, similar to how the LIC 279 serves to acquire critical details for licensing family child care homes.

Dos and Don'ts

When filling out the Lic 279 form for a Family Child Care Home License, attention to detail is essential. Here is a list of actions to guide you through the process:

  • Read the Instructions Carefully: Before starting, review all instructions provided for clarity on what is required.
  • Print Clearly: Use clear, legible print or type the information to avoid misunderstandings.
  • Provide Accurate Information: Double-check that all names, addresses, and dates are correct to prevent processing delays.
  • List Relevant Details: If you have lived in multiple counties recently, ensure you list all of them as required.
  • Sign and Date Every Document: Ensure all applicants sign and date the application to validate it.
  • Attach Required Documentation: Include any necessary attachments, like maps or additional pages, if more space is needed.
  • Pay the Application Fee: Remember to include the licensing fee as specified to complete your submission.

Moreover, there are specific pitfalls to avoid:

  • Do Not Provide Incomplete Information: Failing to fill out every section can result in application rejection.
  • Avoid Abbreviations: Refrain from using abbreviations; write out names of counties and other entities in full.
  • Do Not Misrepresent Facts: Providing false information can lead to legal consequences, including perjury.
  • Do Not Forget to Inform All Parties: Ensure the property owner is aware of your licensing application if renting.
  • Do Not Skip Acknowledging Responsibilities: Familiarize yourself with and acknowledge all responsibilities to prevent future legal issues.
  • Do Not Delay Submission: Submit your application in a timely manner to ensure you are compliant with all licensing requirements.
  • Avoid Leaving Sections Blank: Leaving any sections empty may halt the progress of your application.

By following these do's and don’ts, you can increase the likelihood of a smooth and successful licensing process.

Misconceptions

Misconceptions about the LIC 279 form can lead to confusion and potential errors in the licensing process. Here are four common misconceptions explained:

  1. Only New Applicants Must Fill Out the LIC 279 Form.

    This is not true. The LIC 279 can also be used for capacity changes, location changes, and updates. Whether you are applying for a new license or making adjustments to an existing one, the application is necessary to keep your records current and compliant.

  2. Your Email Address Is Mandatory.

    In fact, providing an email address is not required when filling out the LIC 279 form. While it can facilitate communication with the licensing agency, applicants can leave this field blank if they prefer.

  3. The Form Is Only Relevant for Family Child Care Providers.

    This misconception overlooks the transferability of the form’s insights. Although primarily designed for Family Child Care Homes, the principles of safety, regulatory compliance, and accurate reporting apply to various care settings. Understanding these concepts can benefit other types of care providers as well.

  4. Filing the Form Automatically Grants a License.

    This is misleading. Completing and submitting the LIC 279 is just the first step in the licensing journey. After the form is filed, the licensing agency must conduct inspections and assessments before a license is officially granted.

Key takeaways

Filling out the Lic 279 form requires careful attention to detail. Each section must be completed accurately to avoid delays in the application process. Ensure all information is clear and legible.

Identify the type of application you are submitting. Whether it’s a new application, capacity change, location change, or an update, being clear about your request helps in processing the application efficiently.

Ensure all applicants meet the necessary requirements. All applicants must be over 18 and reside in the home you wish to license. It’s essential that you provide accurate information about other adults living in the home as well.

Account for the children in your care. Include details of any children currently residing in your home on the separate LIC 279B form. This information is confidential and crucial for the licensing process.