Application For A Community Care Facility
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1
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICATION FOR A COMMUNITY CARE FACILITY OR RESIDENTIAL CARE FACILITY
FOR THE ELDERLY LICENSE
(See Instructions on next page)
REPLY TO:
FOR DEPARTMENT USE ONLY
DISTRICT:
COUNTY:
FACILITY NUMBER:
DATE:
ACTION TYPE:
REVIEWED BY:
FACILITY TYPE:
1.
APPLICANT(S) NAME(S) (PLEASE PRINT)
2. REQUESTED ACTION (CHECK ONE):
■
■
A. INITIAL APPLICATION
E. CHANGE OF AMB/NON-
■
B. CHANGE OF CAPACITY
AMB BEDRIDDEN STATUS
■
■
C. CHANGE OF LOCATION
F. CHANGE WITHIN CORPORATION
■
■
D. CHANGE OF FACILITY TYPE
G. OTHER (Specify)
3.
APPLICANT MAILING ADDRESS
CITY
STATE
ZIP CODE
AREA CODE/TELEPHONE
(
)
4.
TYPE OF AGENCY OR FACILITY
■
■
■
ADULT RESIDENTIAL FACILITIES
SOCIAL REHABILITATION FACILITIES
RESIDENTIAL FACILITIES--ELDERLY
■
■
■
FOSTER FAMILY AGENCIES
ADOPTION AGENCIES
RESIDENTIAL FACILITIES--CHRONICALLY ILL
■
■
■
ADULT DAY PROGRAMS
GROUP HOMES
SMALL FAMILY HOMES
■
■
■
TRANSITIONAL HOUSING PLACEMENT PROGRAMS
CRISIS NURSERIES
OTHER( SPECIFY)________________________
5.
APPLICATION
A.
INDIVIDUAL
B.
PARTNERSHIP
C. NON PROFIT CORP.
G. LIMITED LIABILITY
CORPORATION
FILED BY:
D.
PROFIT CORP
E.
COUNTY
F.
OTHER PUBLIC AGENCY
AREA CODE/TELEPHONE
EMAIL ADDRESS (NOT REQUIRED)
6.
FACILITY OR AGENCY NAME
(
)
7.
FACILITY STREET ADDRESS
CITY
COUNTY
ALTERNATIVE PUBLIC
ZIP CODE
TELEPHONE
(
)
8.
FACILITY MAILING ADDRESS
CITY
STATE
ZIP CODE
9.
ADMINISTRATOR OR PERSON IN CHARGE OF FACILITY
TITLE
10B. NUMBER OF BEDRIDDEN UNABLE TO TURN OR REPOSITION
10.
TOTAL REQUESTED CAPACITY
10A.
NUMBER OF NON-AMBULATORY (IF ANY)
IN BED (IF ANY)
11. FOR CHILDREN’S FACILITY ONLY:
NUMBER OF INFANTS (AGES 0 THROUGH 2) ___________
CHILDREN (AGES 3 THROUGH 17) _____________
12.
DAYS AND HOURS OF OPERATION:
13.
PROPERTY OWNERSHIP:
■
■
■
OWN
RENT
OTHER (SPECIFY)
__________________________________________________________________________
13A. NAME, ADDRESS AND PHONE NUMBER OF PROPERTY OWNER, IF RENTING OR LEASING:
14.
WAS FACILITY PREVIOUSLY LICENSED? IF YES, FACILITY NAME AND NUMBER:
LICENSING AGENCY NAME:
■
■
YES
NO
15.
IS MAJOR CONSTRUCTION REQUIRED?
16.
SOURCE OF WATER FOR HUMAN CONSUMPTION
DATE CONSTRUCTION TO BEGIN: ______________________________________
■
■
■
■
YES
NO
PUBLIC
PRIVATE
DATE TO BE COMPLETED:
_________________________________________________
17.
ENTER THE INFORMATION BELOW FOR ANY RESIDENTIAL CARE OR HEALTH CARE FACILITY PREVIOUSLY OR CURRENTLY OPERATED. REFER TO INSTRUCTIONS.
FACILITY NAME AND NUMBER
LICENSING AGENCY NAME
A.
______________________________________________________________________________________________________________________________________________________________________________________
B.
______________________________________________________________________________________________________________________________________________________________________________________
18.
APPLICANT(S)/LICENSEE(S) RESPONSIBILITIES:
A. IN ADDITION TO COMPLYING WITH THE HEALTH AND SAFETY CODES AND REGULATIONS APPLICABLE TO LICENSING AND FIRE SAFETY, I/WE UNDERSTAND THAT THERE MAY BE
OTHER STATE, FEDERAL AND/OR LOCAL LAWS, WHICH ARE NOT ENFORCED BY THIS AGENCY, THAT MAY NEED TO BE MET SUCH AS: ZONING, BUILDING, SANITATION AND LABOR
REQUIREMENTS.
B.
I/WE HAVE READ AND UNDERSTAND THE STATUTES AND REGULATIONS WHICH PERTAIN TO MY/OUR LICENSING CATEGORY PRIOR TO THE ISSUANCE OF MY/OUR LICENSE.
C. I/WE SHALL ENSURE THAT ALL PERSONS SUBJECT TO FINGERPRINT REQUIREMENTS SHALL HAVE A DEPARTMENT OF JUSTICE CLEARANCE OR A CRIMINAL RECORD EXEMPTION
PRIOR TO EMPLOYMENT, RESIDENCE OR INITIAL PRESENCE IN THE FACILITY AS REQUIRED.
D. IF I/WE OPERATE A FACILITY WHICH PROVIDES CARE AND SUPERVISION TO CHILDREN. I/WE SHALL ENSURE THAT A CHILD ABUSE INDEX CHECK FORM FOR EACH PERSON SUBJECT TO
FINGERPRINT REQUIREMENTS IS SUBMITTED TO THE DEPARTMENT OF JUSTICE AS REQUIRED.
E. I/WE SHALL OBTAIN APPROVAL FROM THE LICENSING AGENCY PRIOR TO MAKING ANY CHANGE(S) THAT AFFECT THE TERMS OF THE LICENSE.
19.
I/WE UNDERSTAND THAT I/WE HAVE THE RIGHT TO APPEAL ANY DECISION REGARDING THE DISPOSITION OF THIS APPLICATION.
20.
I/WE DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS APPLICATION AND ON THE ACCOMPANYING ATTACHMENTS ARE CORRECT TO THE BEST OF MY/OUR
KNOWLEDGE.
21.
I/WE AM/ARE AUTHORIZED TO SIGN THIS APPLICATION ON BEHALF OF THE NAMED APPLICANT.
SIGNED
TITLE
COUNTY WHERE SIGNED
DATE
SIGNED
TITLE
COUNTY WHERE SIGNED
DATE
LIC 200 (2/11) PUBLIC
PAGE 1 OF 2
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