JL Family Care Services LLC — Provider Onboarding

Full legal name

First NameLast Name

Email

Phone

Area CodePhone Number

Home address

Street Address

Street Address Line 2

CityState / Province

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Provider type

Service code(s) you will provide

Desired hours per week

Earliest date you can start

MonthDayYear

Are you at least 18 years old?

Are you legally eligible to work in the United States?

Do you have a valid driver license and auto insurance?

Do you have reliable transportation to members' homes?

A DOJ/FBI Live Scan fingerprint background check is required for all positions. If offered a job, are you willing to complete it?

Your relationship to the member you will support

Anything we should know about how your paid hours will be kept separate from your regular parenting/caregiving time?

Relevant experience (caregiving, direct support, respite, independent living)

Most recent job — employer, job title and dates

Most recent job — main duties

Previous job — employer, job title and dates

Previous job — main duties

Highest education completed

Languages spoken

Days available

Times you can work

Reference 1 — name

Reference 1 — phone

Area CodePhone Number

Reference 1 — relationship to you

Reference 2 — name

Reference 2 — phone

Area CodePhone Number

Reference 2 — relationship to you

Government photo ID (photo or scan)

Browse Files

ID expiration date

MonthDayYear

Proof of eligibility to work (document image)

Browse Files

Qualifications: resume, diploma, or other qualifying documents

Upload a File

CPR and First Aid are required for all positions. Which certifications do you currently hold? (you will upload them on the Training Upload form)

CPR expiration date

MonthDayYear

First Aid expiration date

MonthDayYear

Other certifications (DSP, CNA, HHA or others)

A TB test within the last 12 months is required for all positions. Have you had a TB test in the last 12 months?

Position: Direct Support Worker (Parent-Provider or Staff), JL Family Care Services LLC, Apple Valley, California. Reports to: Magaly Reyes, Administrator / Program Supervisor. Status: Part-time, hourly, non-exempt. Services: 862 In-Home Respite, 062 Personal Assistance, 520 Independent Living.

Purpose. The Direct Support Worker provides non-medical, in-home and community support to members referred by Inland Regional Center (IRC). Support follows each member's Individual Program Plan (IPP) and only the services IRC has authorized.

Duties for every service

Provide only the services IRC has authorized for your assigned member, and only for the authorized hours.
Follow the member's IPP goals and any health care, behavior support or emergency plan you were trained on.
Keep the member safe and treat the member and family with dignity and respect.
Complete a Service Note and Timesheet after every shift: date, actual start and end time, location, supports provided, IPP goals worked on and how the member responded.
Use Electronic Visit Verification (EVV) to check in and out when it is required for the service.
Report any incident, injury, illness or unusual event right away. Call 911 first in an emergency, then call the office and complete an Incident Report the same day.
Follow mandated reporter rules for suspected abuse or neglect.
Keep all member information confidential and follow the HIPAA and privacy policies you signed.
Tell the office about schedule changes, absences or concerns as soon as you know.

862 In-Home Respite

Supervise the member and keep them safe so the family caregiver can take a break.
Follow the family's routine for meals, activities and bedtime.
Help with personal care during the visit when needed.

062 Personal Assistance

Give hands-on help with daily living: bathing, dressing, grooming, toileting, eating and moving around safely.
Help with household tasks tied to the member's needs, such as simple meal preparation and light cleaning.
Give medication reminders only. Do not give or measure medication.

520 Independent Living

Teach and practice living skills toward the member's IPP goals: cooking, shopping, budgeting, cleaning, using transportation and staying safe.
Coach step by step so the member does as much as possible on their own.
Record progress toward each goal in the service note.

Qualifications

At least 18 years old.
Able to read, write and communicate well enough to follow the member's plans and complete service notes (English or Spanish).
Skills, training or experience to perform the assigned service.
862 In-Home Respite: current CPR and First Aid certification.
062 and 520: CPR and First Aid if IRC requires it for the service or the member's plan.
Background check or fingerprint clearance, TB screening and exclusion screening as required by IRC and JL Family Care Services LLC policy.
Valid photo ID and proof of eligibility to work in the United States.

Limits of the job

Non-medical care only. Do not give injections, tube feedings, wound care or any skilled nursing task.
Do not bill hours that overlap with the member's school, day program, another paid service or another job.
Do not accept money, gifts or loans from the member or family.
Do not bring other people to the member's home or activities without the office's approval.
Do not post photos or information about the member anywhere.

Parent-Providers (only when the worker is the member's parent or guardian)

You may be paid only after JL Family Care Services LLC has IRC's written confirmation that a parent may be paid for this member and service.
Paid hours must be separate from ordinary parenting. Record only the authorized support you provided, never general household or parenting time.
The same rules for notes, timesheets, EVV, incidents and supervision apply to you as to any other worker.

Working conditions

Work takes place in the member's home and in the community (stores, parks, appointments).
May include standing, walking, bending and lifting or assisting up to 50 pounds with safe techniques.
May include driving the member in your own vehicle only if approved by the office, with a valid license and insurance.

Training and supervision

Complete orientation before your first shift: confidentiality and HIPAA, mandated reporting, incident reporting, EVV and timekeeping.
Complete member-specific training on each member's health care, behavior or emergency plan before working with that member.
Keep CPR, First Aid and other certifications current, and upload renewals before they expire.
Take part in supervision visits and check-ins with the Program Supervisor, and follow corrective action when asked.

Employment terms. Employment with JL Family Care Services LLC is at will. Either you or the company may end it at any time, with or without cause or notice. This duty statement is not a contract, and the company may update it. Hours depend on each member's IRC authorization and are not guaranteed.

By checking the box below and signing this form, I confirm I have read this duty statement, I understand it, and I agree to follow it. I understand that breaking these rules may lead to corrective action, including ending my employment.

Duty statement acknowledgment

Attestation

Signature

Date signed

MonthDayYear

JL Family Care Services LLC — Provider Onboarding

Parent-Provider Information

Experience & Availability

References

Documents (upload only — do not type any ID numbers)

Duty Statement — Direct Support Worker