Application For Administrator Certification - State Of California - Health And Human Services Agency

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
APPLICATION FOR ADMINISTRATOR CERTIFICATION
For Office Use Only:
ADMINISTRATOR CERTIFICATION PROGRAM
PRINTS TO DOJ: ________________
DOJ CLEARED: _________________
Instructions: See page 2 for complete instructions.
FBI CLEARED: __________________
(1) Type of Application: (Check one box only. If renewing, provide certificate number
CACI: _________________________
and expiration date.)
FACILITY #: ____________________
I
New
I
Renewal Certificate #____________________ Expires: ___________
D.O. #: ________________________
LIS #: _________________________
(2) Type of Program: (Check one box only; if applying for more than one certificate,
submit separate application for each.)
I
ARF (Adult Residential Facility)
I
GH (Group Home)
I
RCFE (Residential Care Facility for the Elderly)
I
STRTP (Short Term Residential Therapeutic Program)
(3) Applicant Information: (Please print.)
Check here if any information has changed since last submittal.
I
Name (First, MI, Last): __________________________________________________________________________
Address (Street Address, City, State, Zip): ___________________________________________________________
Telephone Number: ____________________ Cell: ___________________ E-mail: _________________________
Social Security Number:*___________________________ Date of Birth: (MM/DD/YY) ______________________
(a) Do you currently hold or have you previously held a license, certification or other approval as a professional in a
specified field (e.g., RN, NHA)? If yes, please list the type(s) of license(s) or certificate(s) and their number(s).
(Include any Administrator Certificates.)
I
YES
I
NO
(b) Do you currently hold or have you previously held a State-issued care facility license? If yes, please list the type
of license(s) and license number(s). (Include any community care facility licenses.)
I
YES
I
NO
(c) Are you currently employed or were you previously employed by a State-licensed care facility? If yes, please list
the facility name(s) and license number(s). (Place an * by those where currently employed.)
I
YES
I
NO
(d) Have you been the subject of any legal, administrative, or other action involving licensure, certification or other
approvals as specified in (a), (b), and (c) above? If yes, please explain and provide the date(s). (Include any
Administrative Actions. Attach additional pages if more space is needed.)
YES
NO
I
I
(4) For INITIAL APPLICANTS ONLY, indicate when you would like your certificate to expire. (Select one box only. If
you do not select one, two years from issuance will be used.)
I
Two years from date of certificate issuance.
I
Your birthdate of the second calendar year from certificate issuance. (This irrevocable selection means your initial
certificate term may be for more or less than two full years.)
(5) Applicant Certification: I declare that the foregoing information is true and correct to the best of my knowledge.
Applicant Signature: ____________________________________________ Date: __________________________
* Optional but requested for CDSS use only to assist in verifying identity and licensing affiliations. Federal law (at Title 5 United States Code Section 552a Note) states that:
Any federal, state, or local government agency which requests an individual to disclose his social security account number shall inform that individual whether that
disclosure is mandatory or voluntary, by what statutory or other authority such number is solicited, and what uses will be made of it.
LIC 9214 (5/16)
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