The LIC 500 personnel report is the roster California requires every licensed community care facility to keep on file and submit to the Community Care Licensing Division (CCLD), listing everyone connected to the facility so the state can confirm each person has cleared a background check before having contact with clients.1California Department of Social Services. LIC 500 Personnel Report You download the current PDF from the California Department of Social Services (CDSS), complete it in ink or by typing, send the original to your regional office, and keep a copy on site that you update every time your personnel changes.
Who Goes on the Form
The form’s instructions define its scope broadly: it covers “all the facility personnel, other adults and licensees residing in the facility, including backup persons, volunteers and licensee if administrator/director.”1California Department of Social Services. LIC 500 Personnel Report California Health and Safety Code Section 1596.871 sets the corresponding background-check categories, and they line up with who belongs on the roster:2California Legislative Information. California Health and Safety Code 1596.871
- Administrators, supervisors, caregivers, and any staff with client contact.
- Volunteers who regularly interact with the people in your care.
- Residents of the facility other than children, including adult family members or roommates in a home-based facility.
- Backup persons who step in when primary staff are absent.
- If the licensee is a corporation, partnership, or association, the CEO or a designated operations manager.
When in doubt, include the person. Leaving off someone who should be listed is a citable deficiency during inspection.
Completing the Form
Download the current version from the CDSS forms page at cdss.ca.gov/inforesources/forms-brochures/forms-alphabetic-list/i-l.3California Department of Social Services. Forms and Publications (I-L) The form is a single page: a header at the top, a personnel roster below, and a separate section at the bottom for anyone claimed as exempt from background-check requirements.
Header
Enter your facility name, facility type, and facility number exactly as they appear on your license. Add the name of the person preparing the report and the date. The regional office matches these fields to your license file, so any mismatch slows processing.
Personnel Roster
Each row is one person. Fill in the following for every entry:1California Department of Social Services. LIC 500 Personnel Report
- Full legal name, matching the identification used for the person’s background check. Nicknames or shortened names can cause CCLD to flag a mismatch against Department of Justice records.
- The Licensee/Administrator box, checked if the person is the licensee or serves as administrator or director.
- The date the person started working, volunteering, or residing at the facility.
- The specific job title, such as teacher, cook, household member, or volunteer.
- The scheduled days and shift times (FROM and TO). For residents living on site, indicate their presence accordingly.
If a staff member holds a professional license or certificate, such as a social worker credential or nursing license, the form instructions direct you to show the license or certificate number next to their entry. This applies to any specialized staff such as social workers and consultants.
Section B: Exempt Staff
The bottom of the form has a separate section for individuals you believe are exempt from criminal background check requirements under Health and Safety Code Sections 1522, 1568.09, 1569.17, or 1596.871. List each exempt person there. The licensee or designated representative must sign and date the section, verifying under penalty of perjury that each listed person qualifies. Getting an exemption designation wrong exposes you to immediate civil penalties, so treat this section with care.
Background Clearance Before Anyone Starts
The form states the rule plainly: “A California background clearance or a criminal record exemption shall be obtained prior to employment, residence or initial presence in the facility.”1California Department of Social Services. LIC 500 Personnel Report Fingerprinting and clearance happen before the person sets foot in your facility as a worker, volunteer, or resident. Not during the first week. Before.
The process runs through Live Scan. Your facility provides the Live Scan form to the individual, and it carries information unique to your agency that links results back to your facility. Fingerprints are electronically transmitted to the Department of Justice, which processes them and forwards results to the Care Provider Management Bureau of the CCLD.4California Department of Social Services. Live Scan Application Process and Associated Fees Until the clearance or exemption comes back, the person cannot be listed as active personnel.
One boundary worth flagging: if someone has lived outside California within the past five years and will work in a children’s residential facility, an Out of State Child Abuse Check is also required. That runs on a separate form, the LIC 508, and must clear before the person can work, reside, or be present at the facility.5California Department of Social Services. Background Check Process
Filing and Keeping It Current
Send the completed original to your assigned CCLD regional office and keep a copy in your facility file.1California Department of Social Services. LIC 500 Personnel Report You can find your regional office through the CCLD office locator at search.ccl.dss.ca.gov/OfficeLocator.6California Department of Social Services. Child Care Licensing
The LIC 500 is not a one-time filing. Every personnel change requires an updated report: a new hire, a resignation, a volunteer joining or leaving, a household member moving in or out. File the update with the regional office promptly and keep the on-site copy current at all times. Inspectors compare three things: the copy in your facility file, the version the regional office has on record, and the staff they see on site. Any discrepancy among those three can trigger a deficiency notice and a corrective action plan.
Penalties for Getting It Wrong
Personnel violations carry real financial consequences, and the fingerprinting rule is one of the sharpest.
For child care facilities, 22 CCR Section 101195 sets a baseline of $50 per day per cited violation for serious deficiencies not corrected by the deadline, rising to $150 per day in more severe situations.7Legal Information Institute (LII). California Code of Regulations Title 22 101195 – Penalties If anyone required to be fingerprinted is working, residing, or volunteering in your facility without a clearance or exemption, the penalty is $100 per violation per day for up to five days, and a repeat within 12 months extends that to $100 per day for up to 30 days. If a child becomes sick, is injured, or dies as a result of a deficiency, the penalty jumps immediately to $150 per day.
For community care facilities serving adults, Health and Safety Code Section 1548 sets penalties between $25 and $50 per day per violation, capped at $150 per day. Immediate $150-per-day assessments apply for serious violations such as absent supervision, accessible firearms, or the presence of an excluded person on the premises.8California Legislative Information. California Health and Safety Code 1548
During routine and unannounced inspections, licensing evaluators check more than paperwork. They compare your on-site LIC 500 against the version filed with the regional office, observe who is physically on the premises, and may interview staff to confirm that employment dates and roles match. A person present at the facility who doesn’t appear on the roster is enough on its own for a citation.
If You’re Cited
You can challenge a citation through an informal conference under 22 CCR Section 73721.9Legal Information Institute (LII). California Code of Regulations Title 22 73721 – Informal Conference Request the conference from the district administrator, who must schedule it within four business days of your request. At the conference you can bring legal counsel, present oral and written evidence, explain mitigating circumstances, and call witnesses. The proceeding is informal: no subpoenas, no cross-examination, no technical rules of evidence. The district administrator can affirm, modify, or dismiss the citation and any associated civil penalty, and you receive a written decision.
If the decision goes against you, move fast. You have four business days after receiving it to notify the district administrator in writing, by registered or certified mail, that you intend to contest it further. Miss that window and the decision becomes a final order of the Department with no further administrative review. A timely contest sends the matter to the Attorney General for proceedings in Superior Court in the county where your facility is located.