Application For A Community Care Facility Page 2
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1
2INSTRUCTIONS FOR APPLICATION FOR FACILITY LICENSE
Type or print clearly. Prepare application in duplicate. Return original and maintain a copy for your records. Attach to this
application form, a copy of all requested forms and documents including those underlined below.
1.
Applicant(s): Enter the names of the person(s) or organization legally responsible for the facility. Enter full names.
Individuals enter first, middle and last name. If joint application, all applicants must sign this application. Individuals, each
general partner, and chief executive officer or authorized representative of a firm, association, corporation, county, city,
public agency or governmental entity must complete Applicant Information (LIC 215). Corporations and other organizations
also complete Administrative Organization, (LIC 309).
2.
Requested Action: Check appropriate box.
3.
Applicant Mailing Address: Enter legal home mailing address of individual(s) and headquarters mailing address of
corporations. Major partner enters principal business mailing address. Other partner(s) enter principal business mailing
address(es) on Applicant Information (LIC 215). Enter area code with telephone number.
4.
Type of Agency or Facility: Check the appropriate box for type of facility as defined in California Code of Regulations, Title
22. If unknown, enter the name commonly used to identify such a facility in space marked “other”.
5.
Application Filed By: Check appropriate box.
6.
Facility or Agency Name: Enter the name used to designate the single facility under application. If an agency, fill in the name
of the agency which provides the services.
7.
Facility Street Address: Enter the physical location of the facility. If applicant has more than one facility, a separate
application must be completed for each facility. Enter area code with telephone number.
8.
Facility Mailing Address: Enter the address where all mail for the facility from the department/licensing agency should be
sent.
9.
Administrator or Person in Charge of Facility: Enter the name and title of person who will directly supervise the facility. If not
yet employed enter “unknown”.
10. Total Requested Capacity: Enter the total number of persons for whom care will be provided in any 24 hour period.
10A. If applicable, enter the number of beds available for non-ambulatory, unable to independently transfer but who do not need
assistance in turning and repositioning in bed.
10B. If applicable, enter the number of beds available for bedridden, unable to independently turn or reposition in bed.
11. For Children’s Facilities Only: Applicants for children’s residential facilities enter the number of infants and the number of
children to be served.
12. Days and Hours of Operation: Enter days and hours of facility operation.
13. Property Ownership: Check the appropriate box.
13a. Control of Property: If applicant(s) is leasing or renting, enter name, address and phone number of owner of facility
premises.
14. Was Facility Previously Licensed?: Check YES or NO. If yes, enter facility name, number and name of agency that issued
license(s).
15. Is Major Construction Required?: Indicate whether or not the facility is to be constructed or requires major structural
improvements. If yes, enter dates construction is to begin and be completed.
16. Source of Water for Human Consumption?: Check PUBLIC or PRIVATE water source.
17. Other Facilities: H & S Code Section 1520(d), 1568.04(b) and 1569.15(d) require that an applicant disclose, prior or present
service as an administrator, general partner,corporate officer or director of, or as a person who has held or holds a beneficial
ownership of 10 percent or more in any community care, residential care facility for chronically ill, residential care facility for
the elderly, or health care facility (attach separate sheet of paper for additional facilities).
18., 19, and 20. Statement of applicant(s)/licensee(s) responsibilities of compliance with all applicable laws and regulations.
21. SIGNATURES OF ALL APPLICANTS OR AUTHORIZED PERSON(S) (I.E., GENERAL PARTNERS OF A PARTNERSHIP
AND CHIEF EXECUTIVE OFFICER OR DULY AUTHORIZED REPRESENTATIVE FOR ALL CORPORATIONS, PUBLIC
AGENCIES, ETC.)
LIC 200 (2/11) PUBLIC
PAGE 2 OF 2
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