California Form LIC 9054 is a one-page document from the California Department of Social Services that asks you to identify the local fire inspection authority with jurisdiction over your community care facility’s address.1California Department of Social Services. LIC 9054 – Local Fire Inspection Authority Information CDSS uses what you write on it to contact the right agency and arrange the fire clearance inspection your license depends on. The form has nothing to do with criminal background checks; if that is what you are looking for, the correct form is LIC 508.
Why CDSS Needs This Form
Before CDSS will issue a community care facility license, you must obtain a fire clearance from the fire authority with jurisdiction over the property. State law requires every prospective licensee to secure and maintain fire clearance approval from either the local fire enforcing agency or the State Fire Marshal, whichever has primary jurisdiction.2California Legislative Information. California Code Health and Safety Code HSC 1531.18 LIC 9054 is simply how CDSS learns who to call. You name the agency; they handle the request.
The form is required across the full range of CDSS-licensed facilities, including group homes, adult residential facilities, residential care facilities for the elderly, small family homes, adult day programs, and foster family agencies.3California Department of Social Services. LIC 281 – Application Instructions for a Facility License
Filling Out the Seven Fields
LIC 9054 asks for seven pieces of information.1California Department of Social Services. LIC 9054 – Local Fire Inspection Authority Information Enter the date you are completing the form. Write your full legal name as the applicant, matching the name you used on the rest of the application packet. Enter the facility name and the physical street address where the facility is or will be located.
Then identify the local fire inspection authority: the name of the fire department or fire district that has jurisdiction over the facility address, followed by that agency’s mailing address, city, and zip code. That is the entire form. It does not ask for a Social Security number, a driver’s license number, or any personal history.
How to Identify the Right Fire Authority
Your local fire inspection authority is the fire department or fire protection district that responds to calls at your facility’s address. In most incorporated cities, that means the city fire department. In unincorporated county areas, it is usually the county fire authority or a local fire protection district. Where no local agency has jurisdiction, the California State Fire Marshal is the primary fire enforcing agency.
Call the non-emergency line for your city or county fire department and ask whether they handle fire clearance inspections for state-licensed care facilities at your specific address. Have the address in front of you. Jurisdiction can change at street boundaries, particularly near city limits, and listing the wrong agency will delay your fire clearance and your entire license.
Where LIC 9054 Fits in the Application
LIC 9054 is form A16 in the CDSS facility licensing application packet. It is submitted alongside roughly 20 other Section A forms, including the main application (LIC 200), financial documents, personnel records, emergency plans, and the facility sketch.3California Department of Social Services. LIC 281 – Application Instructions for a Facility License The form’s own instructions tell you to return it with your completed application.1California Department of Social Services. LIC 9054 – Local Fire Inspection Authority Information
Send the full packet to the CDSS regional licensing office that serves your area. If any form is incomplete, the licensing agency will return the entire packet, so check every field before mailing. The application instructions recommend keeping a photocopy of everything you send.3California Department of Social Services. LIC 281 – Application Instructions for a Facility License
What Happens After You Submit
Once CDSS has your application and LIC 9054, the licensing agency uses the fire authority information to arrange a fire safety inspection. The clearance confirms the property meets state and local fire safety regulations, covering items such as working smoke detectors, unobstructed exits, properly maintained fire extinguishers, and occupancy compliance.
California law gives the primary fire enforcing agency 30 days to complete the final fire clearance inspection, measured from either the date it receives the request or the date you request the final prelicensure inspection from CDSS, whichever is later.4California Department of Social Services. LIC 9092 – Fire Pre-Inspection/Consultation Request Note Scheduling in practice depends on the agency’s workload, so reach out early.
Consider a Pre-Inspection First
You can ask the fire authority for a pre-inspection before the formal clearance. During the pre-inspection, the agency provides consultation, interprets the fire safety regulations that apply to your facility type, and notifies you in writing of the specific requirements you need to meet before final clearance.4California Department of Social Services. LIC 9092 – Fire Pre-Inspection/Consultation Request Note It is optional, but it lets you fix problems on your own timeline instead of failing the formal clearance and scrambling to correct them.
CDSS provides a separate form, LIC 9092, for requesting the pre-inspection. You can submit it to your local fire authority before or alongside your licensing application.