Form Lic 281d - Application And Supporting Documentation Checklist - Foster Family Agency Page 4
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7CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
7. SURETY BOND (LIC 402)
•
Make sure the bonding agency uses the language found on the LIC 402, if the form itself is not used. The State of
California must be identified as the beneficiary and there must be an effective date and expiration date.
•
Compare the LIC 402 to ensure that the bond is in the amount indicated on the LIC 400.
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Below are examples of situations when a bond is needed. (Because a licensee or facility employee is handling
client cash resources).
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The licensee/facility employee cashes a client’s check at the bank and returns the money to the client. In this
situation, the licensee/facility employee has handled the client’s money.
—
The licensee/facility employee keeps client money in a safe place, including a bank or other financial
institution, and controls its distribution (i.e. hands out money).
•
The original bond with original seal and signatures must be submitted with the application. The form must contain
the original signatures of the applicants/licensees. The licensing agency will not accept photocopied signatures on
this form.
8. MONTHLY OPERATING STATEMENT (LIC 401)
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Instructions are found on the reverse side of the form.
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Make sure the number of clients corresponds with the requested capacity.
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Other facility income must be clear and documented.
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All facility operating costs must be indicated and reasonable (i.e. salaries shown as at least minimum wage).
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Approximately 25 percent of the salaries should normally be added for fringe benefits. If fringe benefits are
applicable, the application should so state and explain why.
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Make sure rent amount corresponds with the lease/rental agreement/mortgage payment.
•
If the applicant is the licensee of another facility, a separate LIC 401 must also be submitted for each licensed
facility. For facilities in operation, this information must reflect the actual operating budget, not an estimate. At the
top of the LIC 401, the applicant is to indicate whether the information contained on the form is estimated or actual.
•
Make sure the form contains both the name of the preparer and the original signature of the applicant(s).
The licensing agency will not accept photocopies of signatures on this form.
LIC 281D (1/17) (PUBLIC - OPTIONAL)
PAGE 4 OF 7
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