California Health & Human Services Agency California Department of Social Services
OUT-OF-STATE DISCLOSURE
Name (Print Clearly):
Courtney Moore
Mailing Address:
25211 Stockport St. APT 183, Laguna Hills, CA 92653
Social Security Number (See Privacy Statement On Reverse):
620-37-0704
Driver’s License/I.D. Number/State: Date of Birth:
Y7521731/California 02/24/2003
Licensed Facility Name: Facility Number:
Newport Institute- Periwinkle 306005661
I. OUT-OF-STATE DISCLOSURE
Have you lived in a state other than California within the last five years? (Check the appropriate box)
Yes No
If YES, complete section below.
OUT-OF-STATE ADDRESSES IN THE PAST 5 YEARS
DATE FROM DATE TO STREET CITY STATE
II. DECLARATION
I declare under penalty of perjury under the laws of the State of California that the above information is true
and correct to the best of my knowledge.
01/15/2025
Signature:_________________________________________________________Date:__________________
INSTRUCTIONS TO LICENSEES ONLY:
If an applicant discloses that they have lived in another state within the last five (5) years, send this form com-
pleted by the applicant, to the Care Provider Management Branch, 744 P Street, MS T9-15-62, Sacramento,
CA 95814.
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State of California – Health and Human Services Agency California Department of Social Services
PRIVACY NOTICE
As Required by Civil Code § 1798.17
Collection and Use of Personal Information: The California Justice Information Services (CJIS) Division
in the Department of Justice (DOJ) and the Care Provider Management Branch (CPMB) in the California
Department of Social Services (CDSS) collect the information requested on this form as authorized by Penal
Code sections 11100-11112; Health and Safety Code sections 1522, 1522.1, 1569.10-1569.24, 1596.80-
1596.879; Family Code sections 8700-87200; Welfare and Institutions Code sections 16500-16523.1;
and other state statutes and regulations. The CJIS Division uses this information to process requests of
authorized entities that want to obtain information as to the existence and content of a record of state or
federal convictions to help determine suitability for employment, or volunteer work with children, elderly,
or disabled; or for adoption or purposes of a license, certification, or permit. In addition, any personal
information collected by state agencies is subject to the limitations in the Information Practices Act and state
policy. The DOJ’s general privacy policy is available at http://oag.ca.gov/privacy-policy.
Providing Personal Information: All the personal information requested in the form must be provided.
Failure to provide all the necessary information will result in delays and/or the rejection of your request.
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.
Access to Your Information: You may review the records maintained by the CJIS Division in the DOJ that
contain your personal information, as permitted by the Information Practices Act. See below for contact
information.
Possible Disclosure of Personal Information: In order to be licensed, work at, or be present at, a licensed
facility/organization, or be placed on a registry administered by the Department, 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 personal 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.).
IMPORTANT INFORMATION
Under the California Public Records Act (Government Code section 7920.000 et seq.), 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 (news media).
In addition, the Department is required to tell people who ask, including the news media, 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. This does not apply to Resource Family Homes, Small Family Child Care Homes,
or the Home Care Aide Registry. The Department shall not release any information regarding Home Care
Aides in response to a Public Records Act request, other than their Home Care Aide number.
The information you provide may also be disclosed in the following circumstances:
• To other persons or agencies where disclosure is necessary for them to perform their legal duties, and
their use of your information is compatible and complies with the law, such as for investigations or for
licensing, certification, or regulatory purposes.
• To another government agency as required by state or federal law.
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State of California – Health and Human Services Agency California Department of Social Services
QUESTIONS ABOUT NOTICE AND RECORD INFORMATION
For questions about this notice, CDSS programs, and the authorized use of your criminal history information,
please contact your local licensing regional office. Regional offices can be found by visiting the Community
Care Licensing Division (https://cdss.ca.gov/inforesources/community-care-licensing) and choosing the
appropriate option under Quick Links - Regional Contacts.
For further questions about this notice or your criminal records, you may contact the Associate Governmental
Program Analyst at the DOJ’s Keeper of Records at (916) 210-3310, by email at
keeperofrecords@doj.ca.gov, or by mail at:
Department of Justice
Bureau of Criminal Information & Analysis Keeper of Records
P.O. Box 903417
Sacramento, CA 94203-4170
Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history
records of the FBI. You have the opportunity to complete or challenge the accuracy of the information
contained in the FBI identification record. The procedure for obtaining a change, correction, or updating an
FBI identification record are set forth in Title 28, CFR, 16.34. You can find additional information on the FBI
website at https://www.fbi.gov/services/cjis/identity-history-summary-checks.
FEDERAL PRIVACY ACT STATEMENT
Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information
is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental
authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders,
and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure
to do so may affect completion or approval of your application.
Principal Purpose: Certain determinations, such as employment, licensing, and security clearances,
may be predicated on fingerprint-based background checks. Your fingerprints and associated information/
biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI
for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification
(NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other
available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your
fingerprints and associated information/biometrics in NGI after the completion of this application and, while
retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by
NGI.
Routine Uses: During the processing of this application and for as long thereafter as your fingerprints
and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to
your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all
applicable Routine Uses as may be published at any time in the Federal Register, including the Routine
Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited
to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for
employment, contracting, licensing, security clearances, and other suitability determinations; local, state,
tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national
security or public safety.
Noncriminal Justice Applicant’s Privacy Rights: As an applicant who is the subject of a national
fingerprint-based criminal history record check for a noncriminal justice purpose (such as an application for
employment or a license, an immigration or naturalization matter, security clearance, or adoption), you have
certain rights which are discussed below.
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State of California – Health and Human Services Agency California Department of Social Services
• You must be provided written notification1 that your fingerprints will be used to check the criminal history
records of the FBI.
• You must be provided, and acknowledge receipt of, an adequate Privacy Act Statement when you submit
your fingerprints and associated personal information. This Privacy Act Statement should explain the
authority for collecting your information and how your information will be used, retained, and shared.2
• If you have a criminal history record, the officials making a determination of your suitability for the
employment, license, or other benefit must provide you the opportunity to complete or challenge the
accuracy of the information in the record.
• The officials must advise you that the procedures for obtaining a change, correction, or update of your
criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34.
• If you have a criminal history record, you should be afforded a reasonable amount of time to correct or
complete the record (or decline to do so) before the officials deny you the employment, license, or other
benefit based on information in the criminal history record.3
You have the right to expect that officials receiving the results of the criminal history record check will use it
only for authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or
executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy
Compact Council.4
If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for
review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you
may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this
process may be obtained at https://www.fbi.gov/services/cjis/identity-history-summary-checks.
If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should
send your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you
may send your challenge directly to the FBI. The FBI will then forward your challenge to the agency that
contributed the questioned information and request the agency to verify or correct the challenged entry. Upon
receipt of an official communication from that agency, the FBI will make any necessary changes/corrections
to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through
16.34.) You can find additional information on the FBI website at
https://www.fbi.gov/services/cjis/identity-history-summary-checks.
1 Written notification includes electronic notification, but excludes oral notification
2 https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement
3 See 28 CFR § 50.12(b)
4 See U.S.C. § 552a(b); 28 U.S.C. § 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616),
Article IV(c)
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