• STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

    CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

  • CRIMINAL RECORD STATEMENT

    State law requires that persons associated with licensed facilities 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 ? You do not need to disclose any marijuana-related offenses covered by the marijuana reform legislationcodified 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.? You do not need to disclose convictions that were a result of one’s status as a victim of human trafficking andthat were dismissed pursuant to Penal Code Section 1203.49, nor any marijuana-related offenses covered bythe 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).

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

    1. It happened a long time ago;
    2. It was only a misdemeanor;
    3. You didn’t have to go to court (your attorney went for you);
    4. You had no jail time or the sentence was only a fine or probation;
    5. You received a certificate of rehabilitation;
    6. 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 NOTREPORT 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.

    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 Bereau

    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.

  • DATE OF BIRTH
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  • LIC 508 (1/03) REQUIRED FORM - NO CHANGE PERMITTED

  • I. Instructions to Respondents:

    If you have been convicted of a crime in California or from another state or in federal court, provide the following information:

  • I certify under penalty of perjury that the above information is true and correct to the best of my knowledge.

  • Date
     / /

  • II. Instructions to Licensees:

    If the person discloses a criminal conviction, review the person’s statement and discuss it with your Licensing Program Analyst (LPA Maintain this form in your facility personnel file andsend a copy to your LPA.

  • 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, the law requires that you complete a criminal background check. (Health and Safety Code sections 1522, 1568.09, 1569.17 and 1596.871) 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.

    The Department is required to tell people who ask, including the press, if some one in a licensed facility has a criminal record exemption. The Department must also tell people who ask, the name of a licensed facility 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.

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