Form Lic 281e - Application And Supporting Documentation Checklist - Short-Term Residential Therapeutic Program
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8CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
APPLICATION AND SUPPORTING DOCUMENTATION CHECKLIST
Short-Term Residential Therapeutic Program
This checklist is intended to assist an applicant in completing and submitting an initial application package and may also be
used to submit revised/updated information to the Department by a licensed Short-Term Residential Therapeutic Program.
FACILITY INFORMATION
(Please type or print clearly.)
Applicant/Licensee Name
Facility License Number , If known
Applicant/Licensee Mailing Address
Contact Person Name
Phone Number
Title
For each form or document submitted, please check “initial” for new application. For a current licensee, please check “revised”
and note the revision date, if you are updating information contained in any of the forms or documents listed below. The following
pages of the Application and Supporting Documentation checklist include a detailed description of the content below.
APPLICATION AND SUPPORTING DOCUMENTATION
Date:
1.
Application for Community Care Facility (LIC 200)
Initial /
Revised
2.
Orientation Certificate
Date Completed:
3.
County Letter of Recommendation
Date of Letter:
4.
Applicant Information (LIC 215)
Initial /
Revised
Date:
5.
Designation of Facility Responsibility (LIC 308)
Initial /
Revised
Date:
6.
Affidavit Regarding Client Cash Resources (LIC 400)
Initial /
Revised
Date:
7.
Surety Bond (LIC 402)
Initial /
Revised
Date:
8.
Monthly Operating Statement (LIC 401)
Initial /
Revised
Date:
9.
Supplemental Financial Information (LIC 401A)
Initial /
Revised
Date:
10.
Balance Sheet (LIC 403)
Initial /
Revised
Date:
11.
Balance Sheet Supplemental Schedule (LIC 403A)
Initial /
Revised
Date:
12.
Financial Information Release And Verification (LIC 404)
Initial /
Revised
Date:
)
13.
Personnel Report (LIC 500
Initial /
Revised
Date:
14.
Personnel Record (LIC 501)
Initial /
Revised
Date:
15.
Health Screening Report Facility Personnel (LIC 503)
Initial /
Revised
Date:
16.
Criminal Record Statement (LIC 508)
Initial /
Revised
Date:
17.
Emergency Disaster Plan (LIC 610C)
Initial /
Revised
Date:
18.
Fire Inspection (LIC 9054)
Initial /
Revised
Date:
19.
Board of Directors Statement (LIC 9165 contained in PUB 326)
Initial /
Revised
Date:
20. Control of Property
Initial /
Revised
Date:
21. Bacterial Analysis of Water
Date:
Initial /
Revised
22. Application or Documentation of Accreditation
Initial /
Revised
Date:
23. Plan of Operation/Program Statement (LIC 9106A)
Initial /
Revised
Date:
LIC 281E (1/17) (PUBLIC - OPTIONAL)
PAGE 1 of 8
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