Form Lic 907 - Transmittal For Processing

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
TRANSMITTAL FOR PROCESSING
DATE
FACILITY NO:
I I
I I
I I
I I
TO:
Processing Clerk
Manager
Licensing Supervisor
Evaluator
I I
I I
NAME OF FACILITY:
FROM:
ACTION:
Send Letter Certified
Expedite
I I
I I
I I
I I
OPEN FILE
REQUEST FIRE CLEARANCE
SECOND REQUEST
PREPARE LICENSE AND LETTER
Total Capacity:_______________
No. of Ambs:_______________
Effective Date: ______________________________________________________
No. of Non Ambs.:_______________
I I
I I
Expiration Date: _____________________________________________________
Currently in Operation:
Yes
No
Facility Type: _______________________________________________________
Age Ranges:________________________________________________________
Number of Buildings: ________________________________________________
Total Capacity: __________ No. of Ambs. __________ Non Ambs. ___________
I I
I I
Restraint:
Yes
No
Age Ranges:________________________________________________________
I I
SEND OVERCONCENTRATION
Client Group: _______________________________________________________
I I
I I
More then 300’
Less than 300’
I I
I I
Special Limitations:__________________________________________________
Within City Limits:
Yes
No
I I
I I
REQUEST CII CLEARANCE FOR: ______________________________________
PROCESS WAIVER/EXCEPTION
I I
___________________________________________________________________
CLOSE FILE EFFECTIVE: _____________________________________________
I I
REQUESTED CERTIFIED COPY OF JUDGMENT OF CONVICTION FOR:
Reason: ___________________________________________________________
___________________________________________________________________
I I
REVIEW: ___________________________________________________________
From Which County: _________________________________________________
SPECIAL INSTRUCTIONS:
LIC 907 (5/00) (PUBLIC/PERSONAL/CONFIDENTIAL DEPENDING ON TYPE OF INFORMATION REFERENCED)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
TRANSMITTAL FOR PROCESSING
DATE
FACILITY NO:
I I
I I
I I
I I
TO:
Processing Clerk
Manager
Licensing Supervisor
Evaluator
I I
I I
NAME OF FACILITY:
FROM:
ACTION:
Send Letter Certified
Expedite
I I
I I
I I
I I
OPEN FILE
REQUEST FIRE CLEARANCE
SECOND REQUEST
PREPARE LICENSE AND LETTER
Total Capacity:_______________
No. of Ambs:_______________
Effective Date: ______________________________________________________
No. of Non Ambs.:_______________
I I
I I
Expiration Date: _____________________________________________________
Currently in Operation:
Yes
No
Facility Type: _______________________________________________________
Age Ranges:________________________________________________________
Number of Buildings: ________________________________________________
Total Capacity: __________ No. of Ambs. __________ Non Ambs. ___________
I I
I I
Restraint:
Yes
No
Age Ranges:________________________________________________________
I I
SEND OVERCONCENTRATION
Client Group: _______________________________________________________
I I
I I
More then 300’
Less than 300’
I I
I I
Special Limitations:__________________________________________________
Within City Limits:
Yes
No
I I
I I
REQUEST CII CLEARANCE FOR: ______________________________________
PROCESS WAIVER/EXCEPTION
I I
___________________________________________________________________
CLOSE FILE EFFECTIVE: _____________________________________________
I I
REQUESTED CERTIFIED COPY OF JUDGMENT OF CONVICTION FOR:
Reason: ___________________________________________________________
___________________________________________________________________
I I
REVIEW: ___________________________________________________________
From Which County: _________________________________________________
SPECIAL INSTRUCTIONS:
LIC 907 (5/00) (PUBLIC/PERSONAL/CONFIDENTIAL DEPENDING ON TYPE OF INFORMATION REFERENCED)

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