Form Lic 281e - Application And Supporting Documentation Checklist - Short-Term Residential Therapeutic Program Page 3
Download a blank fillable Form Lic 281e - Application And Supporting Documentation Checklist - Short-Term Residential Therapeutic Program in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Lic 281e - Application And Supporting Documentation Checklist - Short-Term Residential Therapeutic Program with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
APPLICATION AND SUPPORTING DOCUMENTATION – DESCRIPTIONS
1. APPLICATION FOR A COMMUNITY CARE FACILITY LICENSE (LIC 200)
•
All items are filled out completely.
•
All applicants must sign the application.
•
The application should contain original signatures. The licensing agency will not accept photocopied signatures on
this form.
•
If the application indicates that the applicant previously held a license for a facility, the licensing agency will compare
the Applicant Information Form (LIC 215), and verify that the applicant is not subject to disciplinary action.
•
All persons signing the application must be authorized by the board resolution and the board resolution must be
submitted with this form.
2. ORIENTATION CERTIFICATE
•
Proof of attendance to the Community Care Licensing STRTP Orientation MUST be submitted with an application.
3. COUNTY LETTER OF RECOMMENDATION
•
Prior to submitting an application, a STRTP shall obtain at least one letter of recommendation in support of its
program from a county placing agency.
•
The applicant must submit a list of all county placing agencies they sent their program statement to.
•
If the applicant submits their application without a letter of recommendation in support of its program, the
department shall cease review of the application.
4. APPLICANT INFORMATION (LIC 215)
•
The form is completed for the person designated to act for the board, the signatory and the administrator.
•
If the applicant previously held a license, held a beneficial ownership of 10 percent or more or was an administrator,
general partner, corporate officer, or director of a licensed facility, the licensing agency will research to determine if
the applicant is subject to disciplinary action.
•
The form must contain original signatures. The licensing agency will not accept photocopied signatures on this
form. Reference statements must be current and should not be from relatives.
•
This form will be used as necessary to verify qualifications when an applicant also intends to be the
Administrator/Director.
5. DESIGNATION OF FACILITY RESPONSIBILITY (LIC 308)
•
At least one individual must be designated as the authorized person of the STRTP to act in the licensee’s absence.
A LICENSEE CANNOT DESIGNATE HIM OR HERSELF. More than one staff person may be designated on
a form.
•
A board resolution must authorize the delegation and be submitted with this form.
•
The form must contain the original signatures of the applicants/licensees. The licensing agency will not accept
photocopied signatures on this form.
6. AFFIDAVIT REGARDING CLIENT CASH RESOURCES (LIC 400)
•
Make sure the form is completed and the appropriate box is checked.
•
Make sure a bond is obtained if needed.
•
The form must contain the original signatures of the applicants/licensees. The licensing agency will not accept
photocopied signatures on this form.
LIC 281E (1/17) (PUBLIC - OPTIONAL)
PAGE 3 OF 8
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Fcr 16 - Group Home/short Term Residential Therapeutic Program (strtp) Shelter Costs Declaration And Survey
Legal
Form Dr-1c - Application For Collective Registration For Short-term Rental Of Living Or Sleeping Accommodations - Department Of Revenue, State Of Florida
Financial
Form Dr-1c - Application For Collective Registration For Short-term Rental Of Living Or Sleeping Accommodations - 2012
Financial
Form Dr-1c - Application For Collective Registration For Short-term Rental Of Living Or Sleeping Accommodations
Financial
Related Categories
Parent category: Legal