Enter Dates of Week
Enter Dates of Week
Enter Dates of Week
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
FACILITIES STAFF WORK SCHEDULE
INSTRUCTIONS: This form is to be completed by the licensing evaluator and reviewed by the licensing supervisor.
The purpose of this form is to review staff coverage in large Residential Facilities for 24-hours per day covering a (3) three-week period to
ensure sufficient staff coverage. CAREFULLY review split shifts
, weekend coverage and irregular days off to ensure sufficient staff coverage.
1. Care and Supervision (e.g., Aides)
Employee Name(s)
2. Food Services (e.g, includes cook, dishwasher)
Employee Name(s)
FACILITY NAME
CLIENT/RESIDENT CENSUS LICENSING EVALUATOR DATE
FACILITY NUMBER FACILITY TYPE FACILITY CAPACITY
For The Month(s) 20
Sun Mon Tues
Wed Thurs Fri
Sat Sun Mon
Tues
Wed
Thurs
Fri Sat Sun
Mon
Tues
Wed
Thurs
Fri
Sat
LIC 507 (1/00)
Enter Work Hours
SERVICE AREA AND WORK TITLE
Enter Work Hours Enter Work Hours
Enter Work Hours
Sun
Mon
Tues
Wed Thurs
Fri
Sat
3. Housekeeping (e.g. Maid)
Employee Name(s)
4. Administrative/Clerical Staff
Employee Name(s)
5. Transportation/Maintenance
Employee Name(s)
6. Other
(specify other service areas below)
Employee Name(s)
For The Month(s) 20
Enter Dates of Week Enter Dates of Week Enter Dates of Week
Sun
Mon
Tues
Wed
Thurs
Fri
Sat Sun
Mon
Tues
Wed
Thurs
Fri
Sat
SERVICE AREA AND WORK TITLE
Enter Work Hours Enter Work Hours
FACILITY NAME/NUMBER
FACILITY STAFF WORK SCHEDULE (Continued)
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