Application For Administrator Certification - State Of California - Health And Human Services Agency Page 2
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Instructions:
FOR ALL APPLICANTS: Use the applicable following checklist to ensure your application is complete (including all
supporting forms and fees) and submit it to: CDSS, Administrator Certification Section (ACS), 744 “P” Street,
MS 9-14-47, Sacramento, CA 95814. Keep a complete copy of your package for your records. If you have any
questions about the application process, please call the ACS at (916) 653-9300.
FOR INITIAL APPLICANTS:
To receive your Administrator Certificate, applicant shall be at least 21 years of age, have a high school diploma or
equivalent, such as a General Education Development (GED) certificate, have the required criminal record clearance (or
exemption) on file with the Department of Justice (including, for GH administrators, a Child Abuse Central Index check
clearance), and must submit the following within 30 days of receiving your congratulatory letter:
A copy of the Department’s congratulatory letter verifying a passing exam score. (Keep original for your files.)
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A copy of the Department’s application deadline extension approval letter, if applicable. (Keep original for your
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files.)
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A completed Application for Administrator Certification (form LIC 9214 (05/16))
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A check or money order for $100 payable to the Department of Social Services. Please include your
administrator certificate number on your check. Paper clip your check to your documents; do not staple or glue.
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A copy of your Certificate of Completion of the Initial Certification Training Program (ICTP, provided by ICTP
vendor), or proof of applicable coursework if RCFE/NHA or GH/STRTP applicant.
A completed Criminal Record Statement (form LIC 508 (07/15))
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If you have already been fingerprinted by Live Scan, a copy of the completed Request for Live Scan Service
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(form LIC 9163 (03/11)), signed by the Live Scan operator. (Note: You do not need to wait for your Live Scan
results before submitting your application.)
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If applicable, for RCFE applicants only, a copy of your current Nursing Home Administrator license.
FOR RENEWAL APPLICANTS:
In order to maintain compliance with the provisions of the Administrator Certification Program, you are required to
maintain the criminal record clearance (or exemption), and submit the following information prior to the certificate
expiration date. Note that certificates cannot be renewed if they have been expired for more than four (4) years.
A completed Application for Administrator Certification (form LIC 9214 (01/16))
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A check or money order for $100 payable to the Department of Social Services ( R for $300 if you’re renewing
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after your certificate expired). Please include your administrator certificate number on your check. Paper clip
your check to your documents; do not staple or glue.
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Proof of completion (e.g., copies of completion certificates from course vendors) of forty (40) hours of
continuing education (OR twenty (20) hours for RCFE/NHA certificate holders) sufficiently related by subject
matter and logic to the Core of Knowledge for your certificate type (e.g., ARF, GH, RCFE) and provided by
approved vendors per program regulations. The total units must include:
At least four (4) hours of instruction in laws, regulations, policies and procedural standards that impact your
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type of care facility (e.g., ARF, GH, RCFE)
If not included in your ICTP, at least one (1) hour of instruction in cultural competency and sensitivity in
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issues related to the lesbian, gay, bisexual, and transgender community
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For RCFE (and RCFE/NHA) certificate holders, at least eight (8) hours in subjects related to serving
residents with Alzheimer’s Disease or other dementias
If applicable, for RCFE applicants only, a copy of your current Nursing Home Administrator license.
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For applicants renewing more than two (2) years but less than four (4) years after certificate expired, proof of
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completion of an additional forty (40) hours of continuing education (or 20 for RCFE/NHA certificate holders),
including an additional four (4) hours in laws, etc., and eight (8) hours in dementia subjects as detailed above.
LIC 9214 (5/16)
PAGE 2 OF 2
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