How to Fill Out the LIC 613A: California Personal Rights Form

The California LIC 613A is the Personal Rights form that licensed child care centers give to each child’s parent or guardian at admission, listing the rights guaranteed under Title 22 of the California Code of Regulations. To use it correctly, download the current December 2025 revision from the California Department of Social Services, fill in your facility information and the child’s name, personally review the rights with the parent, obtain their signature, keep the signed original in the child’s file, give the parent a copy, and post a copy where visitors can see it.¹

One quick boundary before the steps: LIC 613A is for child care centers only. Residential Care Facilities for the Elderly use a different form, LIC 613C. If you run or live in an RCFE, this is not your form.

Where to Get the Current Version

The LIC 613A is a free PDF on the CDSS Forms and Publications page under the I–L alphabetical listing. A Spanish version, LIC 613A SP, is on the same page.¹

Check the revision date in the footer before you print a stack. The current version is dated December 2025 and took effect on December 18, 2025. Older copies that live on third-party sites may be missing updated language, and using a superseded version during a licensing inspection is an avoidable citation.

What Information You Fill In

Most of the page is the pre-printed list of rights. The center only completes a handful of fields, and a staff member fills them in for each child at the time of admission.²

Facility name, exactly as it appears on your Community Care Licensing Division record.
Facility street address, also matching your license.
The child’s full name.
The name, address, and phone number of the licensing office that handles complaints for your area.

The licensing office field trips up new operators. It is not your own center’s contact information. It is the local Community Care Licensing Division regional office that would receive a complaint about your facility. Pull the correct address and phone from the CDSS regional office directory before you print. Putting your own number there, or guessing at a regional office, defeats the point of giving parents a direct line to report concerns.

Reviewing the Rights with the Parent

Section 101223(b) of Title 22 requires the center to personally inform each child’s authorized representative of the rights on the form. Handing someone a page to sign at drop-off does not meet the regulation.³

Sit with the parent or guardian, walk through each right, and answer questions. The next section summarizes what you are walking them through.

What the Rights Cover

Section 101223 of Title 22 guarantees these personal rights to every child in a licensed California child care center, public or private.³

To be treated with dignity in personal relationships with staff and others at the center.
To safe, healthful, and comfortable accommodations, furnishings, and equipment appropriate for the child’s needs.
To be free from corporal or unusual punishment, pain, humiliation, intimidation, ridicule, coercion, threats, and mental abuse, including the withholding of food, sleep, shelter, clothing, medication, or aids to physical functioning as discipline.
To be told how to file a confidential complaint with the licensing agency, including the agency’s address and phone number.
To attend religious services or activities on a completely voluntary basis, with parents or guardians deciding for minors.
Not to be locked in any room, building, or facility area at any time, though exterior doors and windows may be locked for general safety as long as children can still exit the building.
Not to be placed in restraining devices. Postural supports are allowed only under the separate rules in Section 101223.1.
To receive or refuse medical care and health-related services, with a guardian, conservator, or other legal authority deciding for minors.

Signing, Filing, and Posting

Once the parent confirms they understand the rights, they sign and date the acknowledgment at the bottom and write in their title, such as “parent” or “legal guardian.”³

Three things happen with the completed form:

The signed original goes into the child’s file at the center, where licensing inspectors can review it.
A copy goes to the parent or guardian so they keep their own record of the rights and the complaint contact information.
A copy is posted in a prominent public spot at the center, usually a lobby, entryway, or sign-in area. The posted copy does not need signatures. It is a general notice so anyone visiting can read the rights at any time.³

Penalties for Skipping It

Failing to provide personal rights notification is a licensing deficiency, and the fines under Section 101195 add up quickly. A serious deficiency that is not corrected by the date in the notice starts at $50 per day per violation and can run to $150 per day. Repeating the same violation within a 12-month window brings an immediate $150 per violation on day one, then daily accrual until the problem is fixed. If a child is sickened, injured, or dies because of a deficiency, the penalty is $150 per day from the start, first offense or not.⁴

Penalties are due on receipt of the payment notice, payable by check or money order, and the CDSS can go to court to collect unpaid amounts. Keeping current forms on file, signed and posted, is the cheapest line item in the operation.

1
California Department of Social Services. Forms and Publications I – L
2
California Department of Social Services. Personal Rights – Child Care Centers
3
New York Codes, Rules and Regulations. California Code of Regulations Title 22 Section 101223 – Personal Rights
4
Legal Information Institute. California Code of Regulations Title 22 Section 101195 – Penalties