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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING

Applicant Submission

1. ORI: A0448
2. Working Title: (Check ✔ one)
■ Adult Resident other than Client ■ Employee
✔ ■ License, Certification, Applicant ■ Volunteer ■ Home Care Aide
Registry Applicant
3. Authorized Applicant Type - Enter from list on Page 2, “DOJ Abbreviated CCLD Facility/Organization Type.”
Resident Care Facility for the Elderly
4. Agency Address Set Contributing Agency:

CA Dept of Social Services 03502

Agency authorized to receive criminal history information Mail Code (five-digit code assigned by DOJ)

PO BOX 94244 Mail Station 9-15-62 N/A

Street No. Street or PO Box Contact Name (Mandatory for all school submissions)

Sacramento, CA 94244-2430 ( ) N/A

City State Zip Code Contact Telephone No.

5. Applicant Information:
Name of Applicant: (Please print)_________________________________________________________________________________
LAST FIRST MI

AKA’s:________________________________________________ CDL No._______________________________________

LAST FIRST

DOB:_________________________ SEX: ■ Male ■ Female Misc. No. BIL -

AGENCY BILLING NUMBER (IF APPLICABLE)

HT:__________________________ WT:____________________ Misc. No.:______________________________________

PERMANENT RESIDENT (i-551), OUT OF STATE DRIVER’S
LICENSE OR I.D.

EYE Color:____________________ HAIR Color:______________ Home Address: (All applicants must complete)

POB:_________________________________________________
STREET OR PO BOX

SOC:_________________________________________________
(See Privacy Statement on Page 4) CITY, STATE AND ZIP CODE

435202847
6. Facility/Organization Number:_______________________________________Level
435202621 of Service ■
✓ DOJ ■
✓ FBI

If resubmission for fingerprint quality (select R2), list Original ATI No.________________________
7. Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only)

Ivy Park at San Jose

Employer Name
4855 San Felipe Road
Street No. Street or PO Box Mail Code (five digit code assigned by DOJ)
San Jose, CA 95135 408-223-1312
City State Zip Code Agency Telephone No. (Optional)
8.
Live Scan Transaction Completed By:______________________________________________ Date__________________________
Name of Operator

Transmitting Agency LSID# ATI No. Amount Collected/Billed

LIC 9163 (12/15) PAGE 1 OF 4
 GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO
USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING
Instructions for the LIC 9163

1. Originating Response Indicator (ORI): Preprinted

2. Working Title: Check the appropriate box

3. Authorized Applicant Type: Indicate the facility type where you will be working.

Select your licensed facility type from the left column, and in the right column find its corresponding DOJ
abbreviated facility type. Enter the corresponding DOJ abbreviated facility type on this line.

Note: In the following table you may be able to identify yourself with more than one facility type within each
category. Please select only one facility type in any category using the facility that you are most associated with on
a day-to-day basis.

If this is your applicable facility type ➯ Enter this abbreviated facility type on your application.

CCLD Facility Type by Category DOJ Abbreviated CCLD Facility Type

Home Care Aide Home Care Aide

Home Care Organization Home Care Organization

Adult Day Care Facility

Adult Day Support Center Adult Day/Resident/Rehab
Adult Residential Facility
Social Rehabilitation Facility

Child Care Center

Infant Center
Mildly Ill Center Day Care Center more/6 Child
School Age Child Care Center

Family Child Care Home Family Day Care

Foster Family Agency

Foster Family / Adoptions Agency Foster Family/Adopt Employment
Foster Family Agency Sub Office

Foster Family Agency - Certified Home

Foster Family Home Foster Family Home

Group Home (6 or less children) Group Home 6/child less

Group Home (7 or more)

Community Treatment Facility Group Home more/6 child

Residential Care Facility for the Chronically Ill

Residential Care Facilities for the Elderly Residential Care Facility Elderly

Small Family Home

Transitional Housing Placement Program Residential Child Care 6/less

LIC 9163 (12/15) PAGE 2 OF 4

4. Agency Address Set Contributing Agency:

Agency authorized to receive criminal history information:

The following information is pre-printed:
Agency: CA Dept of Social Services Mail Code: 03502

Street No.: P.O. BOX 94244, M.S. 9-15-62 Contact Name: N/A

City, State, Zip: Sacramento, CA 94244-2430 Contact Telephone No.: N/A

5. Applicant Information: Print your full name (last, first, middle initial).

AKA’s: Other names the applicant has used CDL No: CA Drivers License or CA ID

DOB: Date of Birth SEX: Male or Female MISC No: BIL - Enter the agency billing
number, if applicable
HT: Height WT: Weight MISC No.: Enter any other identification numbers
(PERMANENT RESIDENT, OUT OF STATE DRIVER’S LICENSE OR I.D.)

EYE Color: Color of eyes HAIR Color: Color of hair Home Address: Applicant’s home address

POB: State or Country of Birth

SOC: Social Security Number (optional) (See Privacy Statement on Page 4)

6. Facility Number: Enter the facility number or assigned OCA number (Agency Identifying Number).

Level of Service: Preprinted

Note: If a Child Abuse Central Index (CACI) check is required, it will automatically be completed by DOJ
and all applicable fees will be charged. There is no entry necessary on the applicant’s part.

If resubmission for fingerprint quality, list Original Applicant Tracking Information (ATI) No.: If your finger-
prints were rejected and this is a resubmission of your prints, enter the original ATI number provided on the reject
notice to avoid paying an additional processing fee.

7. Employer: Enter the facility name and address for which you are being printed.

Employer Name: Enter the facility/organization name.

Street No.: Enter the facility/organization address.
Mail Code: Enter the facility/organization mail code (if applicable).
City, State, Zip: Enter the facility/organization city, state and zip.
Agency Telephone No.: Enter the facility/organization phone number.

8. Live Scan Transaction Completed By: This section will be completed by the Live Scan operator.

Take two copies of this form with you the day you are fingerprinted. The Live Scan Operator will complete
section 8. One copy will be retained by the Operator and the other you may retain for your records.

LIC 9163 (12/15) PAGE 3 OF 4

 PRIVACY STATEMENT

Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code section 1798 et
seq.), notice is given for the request of the Social Security Number (SSN) on this form. The California Department of
Justice uses a person’s SSN as an identifying number. The requested SSN is voluntary. Failure to provide the SSN may
delay the processing of this form and the criminal record check.

In order to be licensed, work at, or be present at, a licensed facility/organization, the law requires that you complete a
criminal background check. (Health and Safety Code sections 1522, 1568.09, 1569.17 and 1596.871). The Department
will create a file concerning your criminal background check that will contain certain documents, including information
that you provide. You have the right to access certain records containing your personal information maintained by the
Department (Civil Code section 1798 et seq.). Under the California Public Records Act, the Department may have to
provide copies of some of the records in the file to members of the public who ask for them, including newspaper and
television reporters.

NOTE: IMPORTANT INFORMATION

The Department is required to tell people who ask, including the press, if someone in a licensed facility/organization has
a criminal record exemption. The Department must also tell people who ask the name of a licensed facility/organization
that has a licensee, employee, resident, or other person with a criminal record exemption.

If you have any questions about this form, please contact your local licensing regional office.

LIC 9163 (12/15) PAGE 4 OF 4