CALIFORNIA 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)
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All items are filled out completely.
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All applicants must sign the application.
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The application should contain original signatures. The licensing agency will not accept photocopied signatures on
this form.
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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.
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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
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Proof of attendance to the Community Care Licensing FFA Orientation MUST be submitted with an application.
3. COUNTY LETTER OF RECOMMENDATION
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Prior to submitting an application, a FFA shall obtain at least one letter of recommendation in support of its program
from a county placing agency.
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The applicant must submit a list of all county placing agencies they sent their program statement to.
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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)
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The form is completed for the person designated to act for the board, the signatory and the administrator.
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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.
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The form must contain original signatures. The licensing agency will not accept photocopied signatures on
this form.
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Reference statements must be current and should not be from relatives.
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This form will be used as necessary to verify qualifications when an applicant also intends to be in the
Administrator/Director.
5. DESIGNATION OF FACILITY RESPONSIBILITY (LIC 308)
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At least one individual must be designated as the authorized person of the FFA 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.
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A board resolution must authorize the delegation and be submitted with this form.
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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)
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Make sure the form is completed and the appropriate box is checked.
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Make sure a bond is obtained if needed.
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The form must contain the original signatures of the applicants/licensees. The licensing agency will not accept
photocopied signatures on this form.
LIC 281D (1/17) (PUBLIC - OPTIONAL)
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