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The LIC 508 form is an essential document for anyone associated with licensed care facilities in California, including applicants for the Home Care Aide Registry or TrustLine Registry. This form requires individuals to disclose any past criminal convictions and undergo fingerprinting as part of a criminal background check. It’s important to note that a conviction is defined broadly, encompassing guilty pleas and verdicts. While the form asks if you've been convicted of any crimes in California, it also covers incidents occurring in other states, federal courts, and military jurisdictions. Certain exemptions apply, particularly regarding marijuana-related offenses or convictions resulting from human trafficking victim status. For individuals involved in foster care, questions about arrests for crimes against children or domestic abuse are also included. The form emphasizes that failure to disclose relevant convictions can lead to serious consequences, including application denials or revocation of licenses. Additionally, if there's a change of address, you must update the Caregiver Background Check Bureau within ten days. This emphasizes the importance of transparency and honesty when filling out this form, which is governed by California law to ensure the safety and well-being of those who might use these care services.

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)

Page 1 of 3

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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Get Lic 508 PDF Form

Form Characteristics

Fact Name Details
Purpose of LIC 508 The LIC 508 form is a Criminal Record Statement and Out-of-State Disclosure required for individuals associated with licensed care facilities in California.
Fingerprint Requirement Individuals must be fingerprinted as part of the background check process to reveal any criminal history.
Disclosure of Convictions All convictions, including misdemeanors, regardless of age or court involvement, must be disclosed unless exempt due to specific laws, such as marijuana reform.
Applicable Laws The process is governed by California Health and Safety Code sections 1522, 1568.09, 1569.17, 1596.871, and 1796.19.
Consequences of Non-Disclosure Failing to report necessary convictions may lead to denial of exemption, application denial, or license revocation.
Address Update Requirement If an individual changes their address, they must notify the Caregiver Background Check Bureau within 10 days to maintain accurate records.

Guidelines on Utilizing Lic 508

Completing the Lic 508 form is a crucial step in the licensure process for individuals associated with care facilities. The following instructions outline how to fill out the form accurately and completely to prevent any delays or issues in processing.

  1. Begin with the **FACILITY/ORGANIZATION/AGENCY NAME** section and fill in the name of the facility or organization you are associated with.
  2. Next, enter the **FACILITY/ORGANIZATION NUMBER** assigned to your facility or organization.
  3. In the **YOUR NAME** field, print your name clearly as it appears on official documents.
  4. Provide your current **ADDRESS** including street, city, state, and zip code. Ensure that this information is accurate and up-to-date.
  5. Fill in your **SOCIAL SECURITY NUMBER**. This step is voluntary, but omitting it may delay processing.
  6. In the **DRIVER’S LICENSE NUMBER/STATE** field, enter your driver's license number and the state that issued it.
  7. Record your **DATE OF BIRTH** in the designated area.
  8. Read the declaration statement carefully. A signature is required in the **SIGNATURE** field to confirm your understanding and accuracy of the information provided.
  9. Finally, enter the **DATE** of signing the form.

Upon completing the form, ensure to double-check for any errors or missing information. Keeping accurate records is essential. Once confirmed, the form can be maintained in the facility's personnel file or sent to the appropriate authority, as per additional instructions provided in the form.

What You Should Know About This Form

What is the purpose of the LIC 508 form?

The LIC 508 form is a Criminal Record Statement and Out-of-State Disclosure form used in California. It is required for individuals associated with licensed care facilities, such as caregivers and applicants for the Home Care Aide Registry or TrustLine Registry. This form ensures that individuals disclose any criminal convictions, enabling the state to verify their background through fingerprinting.

Who is required to fill out the LIC 508 form?

What types of convictions need to be disclosed on the LIC 508 form?

Are there any offenses that do not require disclosure?

What should be done if a person has lived outside of California?

What are the consequences of failing to disclose a conviction?

How should personal information, like the Social Security number, be handled on this form?

Common mistakes

Completing the Lic 508 form accurately is crucial for anyone involved with licensed care facilities. However, several mistakes can lead to issues down the line. First, many applicants do not disclose all necessary convictions. Many people assume that minor offenses or those that occurred a long time ago do not need reporting. This is mistaken; even if a conviction seems insignificant, all convictions—including misdemeanors and those dismissed or set aside—should be disclosed. Failing to do so can result in serious consequences.

Another common error is misunderstanding which offenses to report. Some individuals may believe that marijuana-related offenses are exempt from disclosing under California law. While certain marijuana-related convictions indeed are exempt, this does not apply to all cases. It’s essential to recognize which specific offenses require disclosure, ensuring that nothing is overlooked.

People also frequently ignore the requirement to keep their records updated. If an applicant changes their address or relevant information, they must notify the Caregiver Background Check Bureau within ten days. Failure to update this information can lead to complications with their application status and even potential license revocation.

Many applicants do not read the instructions carefully. Each section of the Lic 508 form has specific guidelines that must be followed. Skimming through these details can lead to incomplete answers. Each "Yes" or "No" must accurately reflect one’s history, ensuring all necessary documentation, such as the LIC 198B for out-of-state disclosures, is submitted. Neglecting these details can hinder the application process.

Another mistake involves incorrectly filling out personal identification details. The form asks for specific information, including the applicant’s Social Security number and driver's license number. Incorrect or missing information can delay or jeopardize the processing of the form, undermining the applicant’s standing.

Finally, there is often confusion about the declaration at the end of the form. Applicants sometimes check boxes or sign without fully recognizing their importance. This declaration states that the applicant is aware that any false statements can lead to severe penalties. Reading and understanding this declaration is essential before signing, as negligence here can result in legal repercussions.

Documents used along the form

The Lic 508 form is a critical document for individuals associated with licensed care facilities in California. Alongside this form, several other documents and forms often accompany the submission process. Each of these documents plays a unique role in ensuring compliance with state regulations and safeguarding the well-being of those under care. Below is a list of these forms and a brief description of each.

  • LIC 198B: This form is required for individuals who have lived outside California within the last five years. It collects information about previous residences and any associated criminal history from those states.
  • LIC 503: This form is used to report any allegations of abuse or neglect. It ensures that necessary actions are taken regarding the welfare of the individuals receiving care.
  • LIC 500: The Personnel Report is submitted to provide information about staff members working in a licensed facility, ensuring background checks are thorough and complete.
  • LIC 9088: This application is for the approval of new licensees. It provides the foundation for evaluating the qualifications of individuals looking to operate care facilities.
  • LIC 915: This form is necessary for periodic background checks on care providers. Regular checks help maintain a safe environment for vulnerable populations.
  • LIC 222: The Increase in Capacity Request form is submitted when a licensed facility intends to expand its capacity. Approval must be obtained before making any changes.
  • LIC 610: This form documents any changes in ownership or control of a licensed facility. Maintaining accurate records is essential for regulatory compliance.
  • LIC 809: This document is the Facility Evaluation Report, which assesses the quality of care provided by the facility. It plays a key role in maintaining standards and accountability.
  • LIC 622: The Emergency Preparedness Plan outlines procedures for responding to emergencies. It is crucial for safeguarding the safety and well-being of residents and staff.

Each of these forms contributes to a comprehensive approach to care facility regulation. The proper completion and submission of these documents foster a safe and compliant environment for all involved. Understanding the importance of each form assures that care facilities uphold the highest standards of care and accountability.

Similar forms

  • LIC 508A - Criminal Background Check: Similar to the LIC 508 form, the LIC 508A focuses on obtaining criminal history and requires disclosure of any past convictions relevant to licensing criteria.
  • LIC 501 - Application for a License: This document also seeks background information, including criminal history, as part of the application process for care facility licenses.
  • LIC 700 - Personnel Record: Similar in purpose, the LIC 700 gathers essential information on staff members, including any relevant criminal convictions.
  • LIC 198B - Out-of-State Criminal Record Statement: This form addresses similar issues for individuals with criminal records from outside California, aiming for comprehensive background checks.
  • LIC 9227 - Health Screening Questionnaire: While focusing on health, this document also requires background disclosures that may intersect with criminal history concerns.
  • LIC 9240 - Serious Incident Report: This form responds to serious incidents within a facility and may require documentation of any criminal history involving staff or residents.
  • LIC 530 - Facility Evaluation Report: Evaluators use this document to assess compliance with regulation, often checking for issues related to any criminal background disclosures.
  • LIC 9110 - Fire Clearance Request: Although focused on safety, this document may interact with prior incidents that involve criminal history affecting facility safety.
  • LIC 9163 - Child Abuse Clearance: This form is used for screening against child abuse history, which aligns with the criminal disclosure required in the LIC 508.
  • LIC 256 - Adult Abuse Reporting Requirements: Similar in scope, it addresses reporting obligations related to any past criminal behavior affecting vulnerable populations.

Dos and Don'ts

When filling out the Lic 508 form, here are six important actions to consider, both what to do and what to avoid.

  • Do answer all questions truthfully to the best of your ability.
  • Do disclose any convictions, including misdemeanors, even if they seem minor.
  • Do keep a copy of the completed form for your records.
  • Do update your mailing address with the Caregiver Background Check Bureau if it changes.
  • Don't omit any offenses simply because a significant amount of time has passed.
  • Don't fail to submit the form by the application deadline.

Taking care to follow these guidelines can ensure the process goes smoothly. Being thorough and honest about your background not only fulfills legal requirements but also supports your future opportunities in the caregiving field.

Misconceptions

Misconception 1: The LIC 508 form is only required for individuals with a criminal record.

This is incorrect. All individuals associated with licensed care facilities must fill out the LIC 508 form, regardless of their criminal history. This includes anyone applying for positions in the Home Care Aide Registry or TrustLine Registry.

Misconception 2: Individuals do not need to disclose old convictions.

In fact, the form requires disclosure of every conviction, regardless of how long ago it occurred. Even if a conviction seems minor or was a long time in the past, it must be reported.

Misconception 3: Marijuana-related offenses do not need to be disclosed under any circumstances.

While it is true that some marijuana-related offenses are exempt under specified health codes, others, particularly those that do not fall under the recent reform legislation, must still be reported. Understanding which offenses are exempt is crucial.

Misconception 4: Arrests automatically disqualify someone from working in a licensed facility.

This is misleading. The LIC 508 form distinguishes between arrests and convictions. An arrest does not necessarily reflect a conviction, and thus may not impact eligibility unless it pertains to specific offenses.

Misconception 5: Only current residents of California need to fill out the form.

This is not accurate. Individuals who have lived in other states within the last five years are also required to provide information on those states. This includes completing additional forms if necessary.

Misconception 6: Submitting the form is a simple process with no implications.

The process carries significant implications. Failing to disclose any convictions may result in serious consequences, including denial of applications or even revocation of licenses. Awareness of the form's requirements is essential.

Misconception 7: The information provided on the LIC 508 form remains confidential.

This is partially true. While personal data is protected, certain information, especially regarding criminal records, may be disclosed under California law to the public, including the press. Understanding these privacy limitations is important for those filling out the form.

Key takeaways

Understanding how to accurately fill out and use the LIC 508 form is essential for compliance with California state laws. Below are key takeaways to keep in mind:

  • The form is necessary for individuals associated with licensed care facilities, including Home Care Aide Registry or TrustLine Registry applicants.
  • You must provide fingerprint information to undergo a criminal history check.
  • A conviction includes any plea of guilty, no contest, or a guilty verdict.
  • Do not disclose marijuana-related offenses covered by specific health and safety codes.
  • Convictions from other states or jurisdictions are treated the same as those in California.
  • If you are a Foster Family Home, you must report arrests related to crimes against a child or spousal abuse.
  • Anyone living in another state within the last five years should list those states and complete an additional form (LIC 198B) for each.
  • Selecting "yes" for any criminal charges requires full disclosure, regardless of the offense's nature or outcome.
  • Failure to report a conviction can result in serious consequences, including denial of exemptions and license revocation.
  • It is essential to update your mailing address with the Caregiver Background Check Bureau within 10 days of any change.

Following these guidelines helps ensure that the form is filled out correctly and increases the likelihood of a smooth processing experience.

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