Request To Add Or Replace Instructor - State Of California - Health And Human Services Agency

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COMMUNITY CARE LICENSING DIVISION

REQUEST TO ADD OR REPLACE INSTRUCTOR

ADMINISTRATOR CERTIFICATION PROGRAM

INSTRUCTIONS: At least 30 days before planning to add or replace an instructor for an approved course, vendors must submit this

completed form and the required supporting documentation to CDSS, ACS, 744 “P” Street, M.S. 9-14-47, Sacramento, CA 95814.

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(1) Type of Application: (Select applicable box(es).)

Add Instructor

Replace Instructor

(2) Vendor Information: (Please print.)

Vendor Number: __________________________________________________________________

Organization/Vendor Business Name:_______________________________________________________________________________________

Address (Street Address, City, State, Zip): ____________________________________________________________________________________

Authorized Representative/Contact Person (Name): ____________________________________________________________________________

Business Phone Number: ______________________ Fax:_________________________ E-mail:________________________________________

(3) Program Information:

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Type: (Check one box only.)

CEU

ICTP

If CEU, Course Title: _______________________________________________________Course Number:_______________________________

If ICTP, select the component(s) of the training the instructor is being proposed to teach.

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Law & Regs

Community & Support Svcs

Cultural Competency

Residents’ Rights

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Business Operations

Physical Needs

Emerg. Intervention/NonViolent

Physical Environment

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Management/Supervision

Medication

Safety of Foster Youth

Postural Supports, Hospice,

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Psych/Social Needs

Admission & Assessment

Alzheimer’s & Dementia

& Restricted Health Cond.

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If ICTP, check if

proposed and/or

replaced instructor is/was fulfilling requirements of 22 CCR 84090(i)(1)(A), 85090(i)(1)(A),or 87785(i)(8).

(4) Instructor Information: (Attach the proposed instructor’s resume.)

Name of Instructor to be Replaced: _________________________________________________________________________________________

Name of Proposed Instructor: __________________________________________________ Social Security Number:*_______________________

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(a) Does the individual currently hold or previously held a license, certification or other approval as a professional in a

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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.)

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(b) Does the individual currently hold or previously held a State-issued care facility license? If yes, please list the type

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of license(s) and license number(s). (Include any community care facility licenses.)

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(c) Is the individual currently employed or previously employed by a State-licensed care facility? If yes, please list the

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facility name(s) and license number(s). (Place an * by those where currently employed.)

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(d) Has the individual been the subject of any legal, administrative, or other action involving licensure, certification or

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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.)

(5) Vendor Certification: I declare that the foregoing information is true and correct to the best of my knowledge.

Printed Name of Vendor/Authorized Representative

Signature of Vendor/Authorized Representative

Date:

Title

DO NOT WRITE BELOW THIS LINE

Date:

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Application has been

approved OR

disapproved by:

* 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 9140A (1/16)