LIC 995A California Parents’ Rights Form: Fields, Posting, and Filing

To fill out LIC 995A, California’s Family Child Care Home Notification of Parents’ Rights, you complete three facility-specific fields near the bottom of the form (your home’s licensed name, your regional licensing office’s name and address, and that office’s phone number), then give a copy to each parent or authorized representative at the time you accept their child into care. The form itself is pre-printed with the list of rights; your job is to personalize it, distribute it with its two companion forms, collect the parent’s signature on the acknowledgment, and keep that signed portion in the child’s file.

Where to Download LIC 995A

Get the form directly from the CDSS forms library at cdss.ca.gov. The current revision is dated 8/08. Print it on standard letter-size paper, keep a clean master, and photocopy from that master each time a new child enrolls so you’re not re-typing the same facility information on every intake.

The Three Fields You Complete

Only three blanks on LIC 995A need your input, all grouped near the bottom of the rights list:

  • Name of Family Child Care Home. Write the full name exactly as it appears on your state-issued license. A mismatch between the form and your license can trigger a deficiency finding during an inspection.
  • Licensing Office Name and Address. Enter the name and street address of your regional Community Care Licensing Division (CCLD) office. Each office covers specific counties. The Sacramento Regional Office, for example, covers Alpine, Amador, Calaveras, El Dorado, Nevada, Placer, Sacramento, San Joaquin, Tuolumne, and Yolo counties. CDSS publishes a master list of regional offices by county as a PDF on the CCLD website.
  • Licensing Office Telephone Number. Include the direct phone number for that regional office so parents can call without hunting for it.

If your home is in Los Angeles County, office assignments go by ZIP code rather than county. Check the Monterey Park and Culver City ZIP-code breakdowns in the CCLD directory before filling in this section.

That’s it for writing on the form. The rest of LIC 995A is pre-printed language you don’t modify.

What the Pre-Printed Form Tells Parents

The body of LIC 995A lists the rights California law guarantees to every parent or authorized representative with a child in your care. Knowing what it says helps you answer questions on the spot. In summary, the form tells parents they can:

  • Enter and inspect your home without advance notice any time children are in care.
  • File a complaint with the local licensing office and review your public licensing file there.
  • Review, at your home, reports of licensing visits and substantiated complaints from the last three years.
  • File complaints and inspect the home without facing discrimination or retaliation against themselves or their child.
  • Receive written notice naming anyone the Department has excluded from being present in your home while children are there (for exclusions on or after January 1, 2001).
  • Request in writing, as a custodial parent with a certified copy of a court order, that another parent not be allowed to visit or remove their child.
  • Get your local licensing office’s name, address, and phone number (which is why you fill in those fields).
  • Ask about any adult in your home who received a criminal record exemption; on request you must disclose the person’s name and type of association to the home.
  • Receive a copy of LIC 995E, the Caregiver Background Check Process form.
  • Be told whether your home carries liability insurance or a bond covering injuries caused by your negligence or that of your employees.

The form also notes that you can deny a parent access if that parent’s behavior poses a risk to children in care. That exception is narrow and doesn’t cover routine drop-in visits or disagreements over care practices.

Companion Forms That Must Go Out With It

LIC 995A doesn’t go out alone. Section 102419(d) requires you to hand parents three documents at the same time:1New York Codes, Rules and Regulations. California Code of Regulations Title 22 Section 102419 – Admission Procedures and Parental and Authorized Representatives Rights

  • LIC 995A, the parents’ rights notification itself.
  • LIC 995E, the Caregiver Background Check Process form, which explains how CDSS fingerprints and screens adults who own, live in, or work at your home, and how criminal record exemptions are reviewed.
  • LIC 9212, the Family Child Care Consumer Awareness Information form, a health-and-safety checklist covering pool safety, emergency preparedness, infant care, and how to file a complaint.

All three are free downloads from the CDSS forms page. Missing any one counts as a separate compliance failure. Keep a stocked supply of all three pre-printed and ready for every enrollment.

Posting on the Wall vs. Giving to Parents

These are two different obligations, and providers sometimes confuse them.

You must post PUB 394, the Family Child Care Home Notification of Parents’ Rights Poster, in a prominent, publicly accessible area of your home at all times children are in care.2California Department of Social Services. Family Child Care Homes Manual – Section 102419 PUB 394 is the poster version of the rights, not LIC 995A. A printout of LIC 995A taped to the wall does not satisfy the posting requirement.

Separately, you must give each parent or authorized representative a personal copy of LIC 995A, along with LIC 995E and LIC 9212, at the time of acceptance of the child into care.1New York Codes, Rules and Regulations. California Code of Regulations Title 22 Section 102419 – Admission Procedures and Parental and Authorized Representatives Rights “At the time of acceptance” means during enrollment or intake, not a week later and not on the first day the child actually attends.

Collecting the Signed Acknowledgment

The bottom portion of LIC 995A is a built-in acknowledgment section. After the parent reads the form, ask them to sign and date it. Their signature confirms they received and read LIC 995A, LIC 995E, and LIC 9212.3California Department of Social Services. LIC 995A – Family Child Care Home Notification of Parents Rights

Get the signature at the enrollment meeting before the parent leaves. Parents who take the form home to read often never return a signed copy, and an unsigned acknowledgment is the same as no acknowledgment at all when an evaluator asks.

Once signed, tear off or photocopy the acknowledgment portion and place it in the child’s file. The regulation is specific: the bottom portion must be kept in the child’s file as proof that the parent or authorized representative has been notified of their rights. The parent keeps the top portion, which is the actual list of rights, as their personal copy.

Filing and Record Keeping

Licensing evaluators can show up unannounced and ask to see any child’s file. Every file should contain the signed acknowledgment, filed so you can pull it quickly. Alphabetical by child’s last name or chronological by enrollment date both work. If an evaluator asks for a signature and you can’t produce it, the gap counts as a deficiency.

The regulation does not specify how long to keep acknowledgments after a child leaves care. Holding onto the file for at least three years is a reasonable practice, since parents are entitled to review substantiated complaint reports going back that far.

Penalties for Getting It Wrong

If a licensing evaluator cites you for a Section 102419 deficiency and issues a plan of correction, and you fail to correct it by the deadline, the Department imposes a civil penalty of $50 per day until you fix the problem.2California Department of Social Services. Family Child Care Homes Manual – Section 102419

Steeper penalties apply to failures involving the excluded-person addendum. Failing to provide a copy of the Addendum to Notification of Parents’ Rights, failing to get a parent’s signature on it, or failing to produce signed addenda when the Department asks for them carries an immediate penalty of $100 per cited violation per day for up to five days.4California Department of Social Services. Family Child Care Homes Manual – Section 102395

Common Mistakes to Avoid

  • Confusing LIC 995A with LIC 995. LIC 995 is the child care center version. Family child care homes use LIC 995A. Using the wrong form is a citable deficiency.
  • Handing out LIC 995A without the companion forms. LIC 995E and LIC 9212 must go out at the same time. Giving parents only the rights notification is technically incomplete.
  • Forgetting to collect the signature. Get the acknowledgment signed at the enrollment meeting, not later.
  • Using outdated licensing office information. Regional office addresses and phone numbers change. Check the CCLD regional office directory at least once a year and update your master copy.
  • Posting LIC 995A instead of PUB 394. The wall posting must be the poster version. The two documents cover similar ground, but the regulation names PUB 394 specifically.