PERSONNEL RECORD

State of California – Health and Human Services Agency
California Department of Social Services
Community Care Licensing Division
Home Care Services Bureau
DOCUMENTS TO UPLOAD
Drivers License / ID

Cancelof
Proof of Right to Work, i.e. US Passport, Green Card, Work Authorization/Permit, US Birth Certificate, or Social Sec. Card

Cancelof
If your Social Sec. Card has restrictions, upload your work permit here

Cancelof
PERSONNEL RECORD
(Form to be kept current at all times)
FOR HOME CARE ORGANIZATION (HCO) USE ONLY
HCO Number
Employee's PER ID
Hire Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Separation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PERSONAL
Name

First NameMiddle InitialLast Name
Area Code/Telephone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Date of TB Test Upon Hire

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Results of Last TB Test
Additional TB Test Dates (Please include test results)
Please list any alternate names used (For example - maiden name)
Do you possess a valid California driver's license?
CDL Number:
POSITION INFORMATION
Title of Position
Notes:
I hereby certify under penalty of perjury that I am 18 years of age or older and that the above statements are true and correct. I give my permission for any necessary verification.
Employee Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HCS 501 (10/19)
Page 1 of 19

ADVANCED HOME CARE SERVICES
8949 RESEDA BLVD. STE 228
NORTHRIDGE CA 91324
TEL: (818)-701-1998 FAX: (818)-701-5466
JOB DESCRIPTION
HOME CARE AIDE/COMPANION
Position description:
A Home Care Aide/Companion is a non-licensed member of the home care team who assists the client with the tasks of daily living. Home Care Aide/Companion receive scheduling direction from the agency staffing Coordinator.
Qualifications:
1. Homemaker/Companion must have a minimum of one year of work experience which is verifiable through references and must complete the agency's employment process.
2. Must be at least 18 years of age.
3. Must be physically able to perform the duties of the position.
4. Must exhibit mature, responsible behavior, and understand the need for patient confidentiality.
5. Must be able to read, write, understand and speak English.
6. Must be able to follow direction. Must have available reliable transportation to and from assignments.
7. Must have and continue a clean Criminal Background report.
Duties:
The duties of a Home Care Aide/Companion may include, but are not limited to the following:
1. Planning and preparing meals
2. Maintaining a safe, clean and healthy environment through light housekeeping including changing bed linens, dusting and vacuuming, cleaning kitchen and bathroom, and laundry.
3. Providing companionship and stimulation for the client including reading, walks, etc.; and accompanying the client to doctors or other appointments
4. Grocery shopping or other errands when needed
5. Assist with bathing, grooming, toileting and incontinence issues
6. Participating in in-service education programs
7. Accompany clients to appointments
8. Providing medication reminders and appointment reminders
Employee Signature:
Agency Authorization Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Page 2 of 19

References
Please list three professional references.
Reference 1
Full Name:
Relationship:
Company:
Phone:
Format: (000) 000-0000.
Address:
Reference 2
Full Name:
Relationship:
Company:
Phone:
Format: (000) 000-0000.
Address:
Reference 3
Full Name:
Relationship:
Company:
Phone:
Format: (000) 000-0000.
Address:
Previous Employment
Company:
Phone:
Format: (000) 000-0000.
Address:
Supervisor:
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Company:
Phone:
Format: (000) 000-0000.
Address:
Supervisor:
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Company:
Phone:
Format: (000) 000-0000.
2
ADVANCED HOME CARE SERVICES
8949 RESEDA BLVD. SUITE 101 NORTHRIDGE, CA 9134
TEL: (818)-701-1998 FAX: (818)-701-5466
EMAIL: Advancedhomecareservices@yahoo.com
Page 4 of 19

Address:
Supervisor:
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Military Service
Branch:
From:
To:
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
Applicant Release (Please read and sign below)
I authorize the investigation of my background including all information contained in this application and information provided in the interview. I understand that misrepresentation or omission of information in connection with my application and interview will be sufficient cause, in and of itself, for rejection or dismissal whenever discovered. I understand and agree that any offer of employment or subcontractor assignment/s is contingent upon satisfactory completion of Advanced Home Care Services pre-employment/pre-subcontractor investigation which includes bit is not limited to health, assessment, criminal history check, educational and work verification, reference checks, consumer report and any investigation required by local, state, or federal laws. I understand that if I'am hired by Advanced Home Care Services, my employment or sub-contracting assignment/s will be for an indefinite period and will be "at will" which means that either Advanced Home Care Services or I may terminate the employment or sub-contracting relationship at anytime and for any reason or no reason.
p
I further understand that, if hired, my at-will employment or sub-contractor status may only be changed in written contract signed by the management of Advanced Home Care Services and that no representative of Advanced Home Care Services has the authority to make oral promise to me concerning my employment or assignments. Finally, I also understand that Advanced Home Care Services may adopt, from time to time, policies or handbooks dealing with benefits and other terms or conditions of employment or sub-contract/s. There policies or handbooks do not constitute a contract of employment or assignment/s between Advanced Home Care Services and me. Advanced Home Care Services reserves the right to change or discontinue these policies and/or handbooks at any time with or without notice me.
Advanced Home Care Services strives to provide a safe, healthy and productive work environment and supports a smoke free, alcohol free work environment.
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
3
ADVANCED HOME CARE SERVICES
8949 RESEDA BLVD. SUITE 10 NORTHRIDGE, CA 9134
TEL: (818)-701-1998 FAX: (818)-701-5466
EMAIL: Advancedhomecareservices@yahoo.com
Page 5 of 19

CONFIDENTIALITY AGREEMENT
ADVANCED HOME CARE SERVICES
Applies to all ADVANCED CAREGIVERS INCORPORATED dba ADVANCED HOME CARE SERVICES (a non-medical caregiver agency) "workforce members" including: employees, sub-contractors, medical staff and other health care professionals; volunteers; agency, temporary and registry personnel' and trainees, house staff, students, and interns (regardless of whether thev are trainees or rotating through and from another institution).
It is the responsibility of all ADVANCED CAREGIVERS INCORPORATED dba ADVANCED HOME CARE SERVICES workforce members, as defined above, as above, including employees, medical staff, house staff, students and volunteers, to preserve and protect confidential patient, employee and business information.
The federal Health Insurance Portability Accountability (the "Privacy Rule"), the Confidentiality of Medical Information Ace (California Civil Code 56 et. Seq) and the Lanterman-Petris-Short Act (California Welfare & Institutions Code 5000 et seq.) govern the release of patient identifiable information by hospitals and other health care providers. The State Information Practices Ace (California Civil Code sections 1798 et seq.) governs the acquisition and use of data that pertains to individuals. All these laws establish protections to preserve the confidentiality of various medical and personal information and specify that such information may not be disclosed except as authorized by law or the patient or individual.
Confidential Patient Care Information includes: Any individually information in possession or derived from a provider of health care regarding a patient's medical history, mental, or physical condition or treatment, as well as the patients and/or their family members records, test results, conversations, research records and financial information. (Note: this information is defined in the privacy rule as "protected health information".) Examples include, but are not limited to:
- Physical medical and psychiatric records including paper, photo, video, diagnostic and therapeutic reports, laboratory and pathology samples;
- Patient insurance and billing records;
- Mainframe and department based computerized patient data and alphanumeric radio pager messaged;
- Visual observation of patients receiving medical care or accessing services; and
- Verbal information provided by or about a patient.
Confidential Employee and Business Information includes, but is not limited to, the following:
- Employee home telephone number and address;
- Spouse or other relative names;
- Social Security number or income tax withholding records;
- Information related to evaluation of performance;
- Other such information obtained from the Company's records which if disclosed, would constitute an unwarranted invasion of performance'
Disclosure of Confidential business information that would cause harm to ADVANCED CAREGIVERS INCORPORATED dba ADVANCED HOME CARE SERVICES agency
ADVANCED HOME CARE SERVICES
8949 RESEDA BLVD STE101 NORTHRIDGE CA 91324
TEL: (818)-701-1998 FAX: (818)-701-5466
EMAIL: Advancedhomecareservices@yahoo.com
Page 6 of 19

CONFIDENTIALITY AGREEMENTADVANCED HOME CARE SERVICES
Peer review and risk management activities and information are protected under California Evidence Code section 1157 and the attorney-client privilege.
I understand and acknowledge that:
1. I shall and maintain the confidentiality of all discussions, deliberations, patient care records and any other information generated in connection with individual patient care, risk management and/or peer review activities.
2. It is my legal and ethical responsibility to protect the privacy, confidentiality and security of all medical records, propriety information and other confidential information relating to ADVANCED CAREGIVERS INCORPORATED dba ADVANCED HOME CARE SERVICES agency and its affiliates, including business, employment and health care providers.
3. I shall only access or disseminate patient care information in the performance of my assigned duties and where required by or permitted by law, and in a manner, which is consistent with officially adopted policies of ADVANCED CAREGIVERS INCORPORATED dba ADVANCED HOME CARE SERVICES agency, or where no officially adopted policy exists, only with the express approval of my supervisor or designee. I shall make no voluntary disclosure of any discussion, deliberations, patient care records or any other patient care, peer review or risk management information, except to persons authorized to receive it in the conduct of ADVANCED CAREGIVERS INCORPORATED dba ADVANCED HOME CARE SERVICES agency affairs.
4. ADVANCED CAREGIVERS INCORPORATED dba ADVANCED HOME CARE SERVICES Administration performs audits and reviews patient records in order to identify inappropriate access.
5. I will access the minimum necessary information to satisfy my job role or the need of the request.
6. I agree to discuss confidential information only in the work place and only for job related purposes and to not discuss such information outside of the work place or within hearing of other people who do not have a need to know about the information.
7. I understand that any and all references to HIV testing, such as any clinical test or laboratory test used to identify HIV, a component of HIV, or antibodies or antigens to HIV, are specifically protected under law and unauthorized release of confidential information may make me subject to legal and/or disciplinary action.
ADVANCED HOME CARE SERVICES
8949 RESEDA BLVD STE NORTHRIDGE CA 91324
TEL: (818)-701-1998 FAX: (818)-701-5466
EMAIL: Advancedhomecareservices@yahoo.com
Page 7 of 19

CONFIDENTIALITY AGREEMENT
ADVANCED HOME CARE SERVICES
8. I understand that the law specially protects psychiatric and drug abuse records, and that unauthorizes release of such information may make me subject to legal and/or disciplinary action.
9. My obligation to safeguard patient confidentiality continues after my termination of employment with the agency, ADVANCED CAREGIVERS INCORPORATED dba ADVANCED HOME CARE SERVICES.
I hereby acknowledge that I have read and understand the foregoing information and that my signature below signifies my agreement to comply with the above terms. In the event of a breach or threatened breach of the Confidentiality Agreement, I acknowledge that the ADVANCED CAREGIVERS dba ADVANCED HOME CARE SERVICES agency may, as applicable and as it deems appropriate, pursue disciplinary action up to and including my termination from ADVANCED CAREGIVERS INCORPORATED dba ADVANCED HOME CARE SERVICES agency.
Print Name:
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ADVANCED HOME CARE SERVICES
8949 RESEDA BLVD STE 101 NORTHRIDGE CA 91324
TEL: (818)-701-1998 FAX: (818)-701-5466
EMAIL: Advancedhomecareservices@yahoo.com
Page 8 of 19

STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT ACKNOWLEDGING REQUIREMENT TO REPORT SUSPECTED ABUSE OF DEPENDENT ADULTS AND ELDERS
NOTE: RETAIN IN EMPLOYEE/ VOLUNTEER FILE
NAME
POSITION
FACILITY
ADVANCED HOME CARE SERVICES
California law REQUIRES certain persons to report known or suspected abuse of dependent adults or elders. As an employee or volunteer at a licensed facility, you are one of those persons - a "mandated reporter."
PERSONS WHO ARE REQUIRED TO REPORT ABUSE
Mandated reporters include care custodians and any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent adult, whether or not paid for that responsibility (Welfare and Institutions Code (WIC) Section 15630(a)). Care custodian means an administrator or an employee of most public or private facilities or agencies, or persons providing care or services for elders or dependent adults, including members of the support staff and maintenance staff (WIC Section 15610.17).
PERSONS WHO ARE THE SUBJECT OF THE REPORT
Elder means any person residing in this state who is 65 years of age or older (WIC Section 15610.27). Dependent Adult means any person residing in this state, between the ages of 18 and 64, who has physical or mental limitations that restrict his or her ability to carry out normal activities or to protect his or her rights including, but not limited to, persons who have physical or developmental disabilities or whose physical or mental abilities have diminished because of age and those admitted as inpatients in 24-hour health facilities (WIC Section 15610.23).
REPORTING RESPONSIBILITIES AND TIME FRAMES
Any mandated reporter, who in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be abuse or neglect, or is told by an elder or dependent adult that he or she has experienced behavior constituting abuse or neglect, or reasonably suspects that abuse or neglect occurred, shall complete form SOC 341, "Report of Suspected Dependent Adult/Elder Abuse" for each report of known or suspected instance of abuse (physical abuse, sexual abuse, financial abuse, abduction, neglect (self-neglect), isolation, and abandonment) involving an elder or dependent adult.
Reporting shall be completed as follows:
- If the abuse occurred in a Long-Term Care (LTC) facility (as defined in WIC Section 15610.47) and resulted in serious bodily injury (as defined in WIC Section 15610.67), report by telephone to the local law enforcement agency immediately and no later than two (2) hours after observing, obtaining knowledge of, or suspecting physical abuse. Send the written report to the local law enforcement agency, the local Long-Term Care Ombudsman Program (LTCOP), and the appropriate licensing agency (for long-term health care facilities, the California Department of Public Health; for community care facilities, the California Department of Social Services) within two (2) hours of observing, obtaining knowledge of, or suspecting physical abuse.
- If the abuse occurred in a LTC facility, was physical abuse, but did not result in serious bodily injury, report by telephone to the local law enforcement agency within 24 hours of observing, obtaining knowledge of, or suspecting physical abuse. Send the written report to the local law enforcement agency, the local LTCOP, and the appropriate licensing agency (for long-term health care facilities, the California Department of Public Health; for community care facilities, the California Department of Social Services) within 24 hours of observing, obtaining knowledge of, or suspecting physical abuse.
- If the abuse occurred in a LTC facility, was physical abuse, did not result in serious bodily injury, and was perpetrated by a resident with a physician's diagnosis of dementia, report by telephone to the local law enforcement agency or the local LTCOP, immediately or as soon as practicably possible. Follow by sending the written report to the LTCOP or the local law enforcement agency within 24 hours of observing, obtaining knowledge of, or suspecting physical abuse.
- If the abuse occurred in a LTC facility, and was abuse other than physical abuse, report by telephone to the LTCOP or the law enforcement agency immediately or as soon as practicably possible. Follow by sending the written report to the local law enforcement agency or the LTCOP within two working days.
SOC 341A (3/15)
Page 9 of 19

- If the abuse occurred in a state mental hospital or a state developmental center, mandated reporters shall report by telephone or through a confidential internet reporting tool (established in WIC Section 15658) immediately or as soon as practicably possible and submit the report within two (2) working days of making the telephone report to the responsible agency as identified below:
- For all other abuse, mandated reporters shall report by telephone or through a confidential internet reporting tool to the adult protective services agency or the local law enforcement agency immediately or as soon as practicably possible. If reported by telephone, a written or an Internet report shall be sent to adult protective services or law enforcement within two working days.
PENALTY FOR FAILURE TO REPORT ABUSE
Failure to report abuse of an elder or dependent adult is a MISDEMEANOR CRIME, punishable by jail time, fine or both (WIC Section 15630(h)). The reporting duties are individual, and no supervisor or administrator shall impede or inhibit the reporting duties, and no person making the report shall be subject to any sanction for making the report (WIC Section 15630(f)).
CONFIDENTIALITY OF REPORTER AND OF ABUSE REPORTS
The identity of all persons who report under WIC Chapter 11 shall be confidential and disclosed only among APS agencies, local law enforcement agencies, LTCOPs, California State Attorney General Bureau of Medi-Cal Fraud and Elder Abuse, licensing agencies or their counsel, Department of Consumer Affairs Investigators (who investigate elder and dependent adult abuse), the county District Attorney, the Probate Court, and the Public Guardian. Confidentiality may be waived by the reporter or by court order. Any violation of confidentiality is a misdemeanor punishable by jail time, fine, or both (WIC Section 15633(a)).
DEFINITIONS OF ABUSE
Physical abuse means any of the following: (a) Assault, as defined in Section 240 of the Penal Code; (b) Battery, as defined in Section 242 of the Penal Code; (c) Assault with a deadly weapon or force likely to produce great bodily injury, as defined in Section 245 of the Penal Code; (d) Unreasonable physical constraint, or prolonged or continual deprivation of food or water; (e) Sexual assault, that means any of the following: (1) Sexual battery, as defined in Section 243.4 of the Penal Code; (2) Rape, as defined in Section 261 of the Penal Code; (3) Rape in concert, as described in Section 264.1 of the Penal Code; (4) Spousal rape, as defined in Section 262 of the Penal Code; (5) Incest, as defined in Section 285 of the Penal Code; (6) Sodomy, as defined in Section 286 of the Penal Code; (7) Oral copulation, as defined in Section 288a of the Penal Code; (8) Sexual penetration, as defined in Section 289 of the Penal Code: or (9) Lewd or lascivious acts as defined in paragraph (2) of subdivision (b) of Section 288 of the Penal Code; or (f) Use of a physical or chemical restraint or psychotropic medication under any of the following conditions: (1) For punishment; (2) For a period beyond that for which the medication was ordered pursuant to the instructions of a physician and surgeon licensed in the State of California, who is providing medical care to the elder or dependent adult at the time the instructions are given; or (3) For any purpose not authorized by the physician and surgeon (WIC Section 15610.63).
Serious bodily injury means an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation (WIC Section 15610.67).
Neglect (a) means either of the following: (1) The negligent failure of any person having the care or custody of an elder or a dependent adult to exercise that degree of care that a reasonable person in a like position would exercise; or (2) The negligent failure of an elder or dependent adult to exercise that degree of self care that a reasonable person in a like position would exercise. (b) Neglect includes, but is not limited to, all of the following: (1) Failure to assist in personal hygiene, or in the provision of food, clothing, or shelter; (2) Failure to provide medical care for physical and mental health needs. No person shall be deemed neglected or abused for the sole reason that he or she voluntarily relies on treatment by spiritual means through prayer alone in lieu of medical treatment; (3) Failure to protect from health and safety hazards; (4) Failure to prevent malnutrition or dehydration; or (5) Failure of an elder or dependent adult to satisfy the needs specified in paragraphs (1) to (4), inclusive, for himself or herself as a result of poor cognitive functioning, mental limitation, substance abuse, or chronic poor health (WIC Section 15610.57).
Financial abuse of an elder or dependent adult occurs when a person or entity does any of the following: (1) Takes, secretes, appropriates, obtains, or retains real or personal property of an elder or dependent adult for a wrongful use or with intent to defraud, or both; (2) Assists in taking, secreting, appropriating, obtaining, or retaining real or personal property of an elder or dependent adult for a wrongful use or with intent to defraud, or both; or (3) Takes, secretes, appropriates, obtains, or retains, or assists in taking, secreting, appropriating, obtaining, or retaining, real or personal property of an elder or dependent adult by undue influence, as defined in Section 15610.70 (WIC Section 15610.30(a)).
SOC 341A (3/15)
Page 10 of 19

Abandonment means the desertion or willful forsaking of an elder or a dependent adult by anyone having care or custody of that person under circumstances in which a reasonable person would continue to provide care and custody (WIC Section 15610.05).
Isolation means any of the following: (1) Acts intentionally committed for the purpose of preventing, and that do serve to prevent, an elder or dependent adult from receiving his or her mail or telephone calls; (2) Telling a caller or prospective visitor that an elder or dependent adult is not present, or does not wish to talk with the caller, or does not wish to meet with the visitor where the statement is false, is contrary to the express wishes of the elder or the dependent adult, whether he or she is competent or not, and is made for the purpose of preventing the elder or dependent adult from having contact with family, friends, or concerned persons; (3) False imprisonment, as defined in Section 236 of the Penal Code; or (4) Physical restraint of an elder or dependent adult, for the purpose of preventing the elder or dependent adult from meeting with visitors (WIC Section 15610.43).
Abduction means the removal from this state and the restraint from returning to this state, or the restraint from returning to this state, of any elder or dependent adult who does not have the capacity to consent to the removal from this state and the restraint from returning to this state, or the restraint from returning to this state, as well as the removal from this state or the restraint from retuming to this state, of any conservatee without the consent of the conservator or the court (WIC Section 15610.06).
AS AN EMPLOYEE OR VOLUNTEER OF THIS FACILITY, YOU MUST COMPLY WITH THE DEPENDENT ADULT AND ELDER ABUSE REQUIREMENTS, AS STATED ABOVE. IF YOU DO NOT COMPLY, YOU MAY BE SUBJECT TO CRIMINAL PENALTY, IF YOU ARE A LONG-TERM CARE OMBUDSMAN, YOU MUST COMPLY WITH FEDERAL AND STATE LAWS, WHICH PROHIBIT YOU FROM DISCLOSING THE IDENTITIES OF LONG-TERM RESIDENTS AND COMPLAINANTS TO ANYONE UNLESS CONSENT TO DISCLOSE IS PROVIDED BY THE RESIDENT OR COMPLAINANT OR DISCLOSURE IS REQUIRED BY COURT ORDER (Title 42 United States Code Section 3058g(d)(2); WIC Section 9725).
I,
have read and understand my responsibility to report known or suspected abuse of dependent adults or elders. I will comply with the reporting requirements.
SIGNATURE
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SOC 341A (3/15)
Page 11 of 19

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?
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.?
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?
For Children's Residential Facilities:
Have you lived in a state other than California within the last five years?
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 12 of 19

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):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SOCIAL SECURITY NUMBER: (See Privacy Statement on Page 3):
DRIVER'S LICENSE NUMBER/STATE:
DATE OF BIRTH:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SIGNATURE:
DATE:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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)
Page 13 of 19

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)
Page 14 of 19

HIPAA EMPLOYEE CONFIDENTIALITY AGREEMENT
THIS AGREEMENT entered into this (date)
(date)
by and between
(Employer) Advanced Caregivers, Inc. dba Advanced Home Care Services known as the Employer
, and (Employee)
(Employee)
"Employee", and known collectively as the "Parties", set forth the terms and conditions under which information created or received by or on behalf of this Healthcare Facility (known collectively as protected health information or "PHI") may be used or disclosed under State law and the Health Insurance Portability and Accountability Act of 1996 and updated through HIPAA Omnibus Rule of 2013 and will also uphold regulations enacted there under. (hereafter "HIPAA").
THEREFORE, in consideration of the premises and the covenants and agreements contained herein, the Parties hereto, intending to be legally bound hereby, covenant and agree as follows:
1. Confidential Information.
The Parties acknowledge that meaningful employment may or will necessitate disclosure of Confidential Information by this Healthcare Facility to the Employee and use of Confidential Information by the Employee. The term "Confidential Information" includes, but is not limited to, PHI, any information about patients or other employees, any computer log-on codes or passwords, any patient records or billing information, any patient lists, any financial information about this Healthcare Facility or its patients that is not public, any intellectual property rights of Practice, any proprietary information of Practice and any information that concerns this Healthcare Facility's contractual relationships, relates to this Healthcare Facility's competitive advantages, or is otherwise designated as confidential by this Healthcare Facility.
2. Disclosure.
Disclosure and use of Confidential Information includes oral communications as well as display or distribution of tangible physical documentation, in whole or in part, from any source or in any format (e.g., paper, digital, electronic, internet, social networks, magnetic or optical media, film, etc.). The Parties have entered into this Agreement to induce use and disclosure of Confidential Information and are relying on the covenants contained herein in making any such use or disclosure. This Healthcare Facility, not the Employee, is the records owner under state law and the Employee has no right or ownership interest in any Confidential Information.
3. Applicable Law.
Confidential Information will not be used or disclosed by the Employee in violation of applicable law, including but not limited to HIPAA Federal and State records owner statute; this Agreement; the Practice's Notice of Privacy Practices, as amended; or other limitations as put in place by Practice from time to time. The intent of this Agreement is to ensure that the Employee will use and access only the minimum amount of Confidential Information necessary to perform the Employee's duties and will not disclose Confidential Information outside this Healthcare Facility unless expressly authorized in writing to do so by this Healthcare Facility. All Confidential Information received (or which may be received in the future) by Employee will be held and treated by him or her as confidential and will not be disclosed in any manner whatsoever, in whole or in part, except as authorized by this Healthcare Facility and will not be used other than in connection with the employment relationship.
4. Log-on Code and Password.
The Employee understands that he or she will be assigned a log-on code or password by Practice, which may be changed as this Healthcare Facility, in its
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sole discretion sees fit. The Employee will not change the log-on code or password without this Healthcare Facility's permission. Nor will the Employee leave Confidential Information unattended (e.g., so that it remains visible on computer screens after the Employee's use). The Employee agrees that his or her log-on code or password is equivalent to a legally binding signature and will not be disclosed to or used by anyone other than the Employee. Nor will the Employee use or even attempt to learn another person's log-on code or password. The Employee immediately will notify this Healthcare Facility's HIPAA Privacy Officer upon suspecting that his or her log-on code or password no longer is confidential. The Employee agrees that all computer systems are the exclusive property of Practice and will not be used by the Employee for any purpose unrelated to his or her employment. The Employee acknowledges that he or she has no right of privacy when using this Healthcare Facility's computer systems and that his or her computer use periodically will be monitored by this Healthcare Facility to ensure compliance with this Agreement and applicable law.
5. Returning Confidential Information.
Immediately upon request by this Healthcare Facility, the Employee will return all Confidential Information to this Healthcare Facility and will not retain any copies of any Confidential Information, except as otherwise expressly permitted in writing signed by this Healthcare Facility. All Confidential Information, including copies thereof, will remain and be the exclusive property of this Healthcare Facility, unless otherwise required by applicable law. The Employee specifically agrees that he or she will not and will not allow anyone working on their behalf or affiliated with the Employee in any way, use any or all of the Confidential Information for any purpose other than as expressly allowed by this Agreement. The Employee understands that violating the terms of this Agreement may, in this Healthcare Facility's sole discretion result in disciplinary action including termination of employment and/or legal action to prevent or recover damages for breach. Breach reporting is imperative.
6. Breach.
The Parties agree that any breach of any of the covenants or agreements set forth herein by the Employee will result in irreparable injury to this Healthcare Facility for which money damages are inadequate; therefore, in the event of a breach or an anticipatory breach, Practice will be entitled (in addition to any other rights and remedies which it may have at law or in equity, including money damages) to have an injunction without bond issued enjoining and restraining the Employee and/or any person involved from breaching this Agreement.
7. Binding Arrangement.
This Agreement shall be binding upon and endure to the benefit of all Parties hereto and to each of their successors, assigns, officers, agents, employees, shareholders and directors. This Agreement commences on the date set forth above and the terms of this Agreement shall survive any termination, cancellation, expiration or other conclusion of this Agreement unless the Parties otherwise expressly agree in writing.
8. Governing Law.
The Parties agree that the interpretation, legal effect and enforcement of this Agreement shall be governed by the laws in the State of California and by execution hereof, each party agrees to the jurisdiction of the courts of the State. The Parties agree that any suit arising out of or relation to this Agreement shall be brought in the county where this Healthcare Facility's principal place of business is located.
9. Severability.
If any provision under this Agreement shall be held invalid or unenforceable for any reason, the remaining provisions and statements shall continue to be valid and enforceable.
IN WITNESS WHEREOF, and intending to be legally bound, the Parties hereto have executed this Agreement on the date first above written, when signing below and after training on HIPAA Law with full understanding this agreement shall stand.
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EMPLOYEE DOCUMENTATION OF HIPAA PRIVACY TRAINING
The Health Insurance Portability Act of 1996 (HIPAA) requires our privacy officer to train employees on our health information privacy policies and procedures to the HIPAA Omnibus Standards of 2013 which also includes HI-TECH and Protected Health Information (PHI), Electronic Protected Health Information (ePHI) and Electronic Health Records (EHR). All employees with treatment, payment or healthcare operations responsibilities, which allow access to protected health information, are trained with updates periodically as State and Federal mandates require. HIPAA also requires that we keep this documentation (that the training was completed) for six years after the training.
I, the undersigned, do hereby certify that I have received, read, understood and agree to abide by this Healthcare Facilities HIPAA Policies and Operating Procedures.
Employee's Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Print Name:
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Employee's Withholding Certificate
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
Give Form W-4 to your employer.
Your withholding is subject to review by the IRS.
OMB No. 1545-0074
2026
Step 1: Enter Personal Information
(a)

First NameLast Name
(b) Social security number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.
(c)
Caution: To claim certain credits or deductions on your tax return, you (and/or your spouse if married filing jointly) are required to have a social security number valid for employment. See page 2 for more information.
TIP: Consider using the estimator at www.irs.gov/W4App to determine the most accurate withholding for the rest of the year if you: are completing this form after the beginning of the year; expect to work only part of the year; or have changes during the year in your marital status, number of jobs for you (and/or your spouse if married filing jointly), dependents, other income (not from jobs). deductions, or credits. Have your most recent pay stub(s) from this year available when using the estimator. At the beginning of next year, use the estimator again to recheck your withholding.
Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, and when to use the estimator at www.irs.gov/W4App.
Step 2: Multiple Jobs or Spouse Works
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.
Do only one of the following.
(a) Use the estimator at www.irs.gov/W4App for the most accurate withholding for this step (and Steps 3-4). If you or your spouse have self-employment income, use this option; or
(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; or
Complete Steps 3-4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3-4(b) on the Form W-4 for the highest paying job.)
Step 3: Claim Dependent and Other Credits
If your total income will be $200,000 or less ($400,000 or less if married filing jointly):
(a) Multiply the number of qualifying children under age 17 by $2,200
(b) Multiply the number of other dependents by $500
Add the amounts from Steps 3(a) and 3(b), plus the amount for other credits. Enter the total here
Step 4: Other Adjustments
(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won't have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income
(b) Deductions. Use the Deductions Worksheet on page 4 to determine the amount of deductions you may claim, which will reduce your withholding. (If you skip this line, your withholding will be based on the standard deduction.) Enter the result here
(c) Extra withholding. Enter any additional tax you want withheld each pay period.
Step 5: Sign Here
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
Employee's signature (This form is not valid unless you sign it.)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employers Only
Employer's name and address
First date of employment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer identification number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 4.
Cat. No. 10220Q
Form W-4 (2026) Created 12/8/25

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Employment
Development
Department
State of California
This form can be used to manually compute your withholding allowances, or you can electronically compute them at www.taxes.ca.gov/de4.pdf
EMPLOYEE'S WITHHOLDING ALLOWANCE CERTIFICATE
Type or Print Your Full Name
Your Social Security Number
Home Address (Number and Street or Rural Route)
Filing Status Withholding Allowances
City, State, and ZIP Code
Fill out ONE of the following (1-3):
1. Number of allowances for Regular Withholding Allowances, Worksheet A
(1 cont.) Number of allowances from the Estimated Deductions, Worksheet B. Total Number of Allowances (A + B) when using the California Withholding Schedules for 2014
OR:
2. Additional amount of state income tax to be withheld each pay period (if employer agrees), Worksheet C
OR:
3. I certify under penalty of perjury that I am not subject to California withholding, I meet the conditions set forth under the Service Member Civil Relief Act, as amended by the Military Spouses Residency Relief Act.
Under the penalties of perjury, I certify that the number of withholding allowances claimed on this certificate does not exceed the number to which I am entitled or, if claiming exemption from withholding, that I am entitled to claim the exempt status.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer's Name and Address
California Employer Account Number
Give the top portion of this page to your employer and keep the remainder for your records.
YOUR CALIFORNIA PERSONAL INCOME TAX MAY BE UNDERWITHHELD IF YOU DO NOT FILE THIS DE 4 FORM.
IF YOU RELY ON THE FEDERAL FORM W-4 FOR YOUR CALIFORNIA WITHHOLDING ALLOWANCES, YOUR CALIFORNIA STATE PERSONAL INCOME TAX MAY BE UNDERWITHHELD AND YOU MAY OWE MONEY AT THE END OF THE YEAR.
PURPOSE: This certificate, DE 4, is for California Personal Income Tax (PIT) withholding purposes only. The DE 4 is used to compute the amount of taxes to be withheld from your wages, by your employer, to accurately reflect your state tax withholding obligation.
You should complete this form if either:
(1) You claim a different marital status, number of regular allowances, or different additional dollar amount to be withheld for California PIT withholding than you claim for federal income tax withholding or,
(2) You claim additional allowances for estimated deductions.
certificate for your state income tax withholding, you may be significantly underwithheld. This is particularly true if your household income is derived from more than one source.
CHECK YOUR WITHHOLDING; After your Form W-4 and/or DE 4 takes effect, compare the state income tax withheld with your estimated total annual tax. For state withholding, use the worksheets on this form, and for federal withholding use the Internal Revenue Service (IRS) Publication 919 or federal withholding calculations.
THIS FORM WILL NOT CHANGE YOUR FEDERAL WITHHOLDING ALLOWANCES.
EXEMPTION FROM WITHHOLDING: If you wish to claim exempt, complete the federal Form W-4. You may claim exempt from withholding California income tax if you did not owe any federal income tax last year and you do not expect to owe any federal income tax this year. The exemption automatically expires on February 15 of the next year. If you continue to qualify for the exempt filing status, a new Form W-4 designating EXEMPT must be submitted before February 15. If you are not having federal income tax withheld this year but expect to have a tax liability next year, the law requires you to give your employer a new Form W-4 by December 1.
The federal Form W-4 is applicable for California withholding purposes if you wish to claim the same marital status, number of regular allowances, and/or the same additional dollar amount to be withheld for state and federal purposes. However, federal tax brackets and withholding methods do not reflect state PIT withholding tables. If you rely on the number of withholding allowances you claim on your Form W-4 withholding allowance
DE 4 Rev. 42 (1-14) (INTERNET)
Page 1 of 4
CU

Page 19 of 19
Should be Empty:

DOCUMENTS TO UPLOAD

PERSONNEL RECORD

PERSONAL

POSITION INFORMATION

JOB DESCRIPTION

Position description:

Qualifications:

Duties:

ADVANCED HOME CARE SERVICES

Employment Application

Applicant Information

Education

High School

College

Other Education

References

Reference 1

Reference 2

Reference 3

Previous Employment

Military Service

Applicant Release (Please read and sign below)

CONFIDENTIALITY AGREEMENT

ADVANCED HOME CARE SERVICES

CONFIDENTIALITY AGREEMENTADVANCED HOME CARE SERVICES

CONFIDENTIALITY AGREEMENT

ADVANCED HOME CARE SERVICES

STATEMENT ACKNOWLEDGING REQUIREMENT TO REPORT SUSPECTED ABUSE OF DEPENDENT ADULTS AND ELDERS

NOTE: RETAIN IN EMPLOYEE/ VOLUNTEER FILE

PERSONS WHO ARE REQUIRED TO REPORT ABUSE

PERSONS WHO ARE THE SUBJECT OF THE REPORT

REPORTING RESPONSIBILITIES AND TIME FRAMES

PENALTY FOR FAILURE TO REPORT ABUSE

CONFIDENTIALITY OF REPORTER AND OF ABUSE REPORTS

DEFINITIONS OF ABUSE

CRIMINAL RECORD STATEMENT & OUT-OF-STATE DISCLOSURE

Instructions to Licensees:

Instructions to Regional Offices and Foster Family Agencies:

PRIVACY STATEMENT

NOTE: IMPORTANT INFORMATION

HIPAA EMPLOYEE CONFIDENTIALITY AGREEMENT

1. Confidential Information.

2. Disclosure.

3. Applicable Law.

4. Log-on Code and Password.

5. Returning Confidential Information.

6. Breach.

7. Binding Arrangement.

8. Governing Law.

9. Severability.

EMPLOYEE DOCUMENTATION OF HIPAA PRIVACY TRAINING

Employee's Withholding Certificate

Step 1: Enter Personal Information

Step 2: Multiple Jobs or Spouse Works

Step 3: Claim Dependent and Other Credits

Step 4: Other Adjustments

Step 5: Sign Here

Employers Only

EMPLOYEE'S WITHHOLDING ALLOWANCE CERTIFICATE

Fill out ONE of the following (1-3):

OR:

OR:

YOUR CALIFORNIA PERSONAL INCOME TAX MAY BE UNDERWITHHELD IF YOU DO NOT FILE THIS DE 4 FORM.