Form Hcs 9165 - Board Of Director Statement
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1CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES BUREAU
BOARD OF DIRECTOR STATEMENT
IMPORT NT
– Before completing this page, please read the Application Instructions for a Home Care Organization License (HCS 281).
Licensees are required to provide evidence that every member of the board of directors understands his or her legal
duties and obligations as a member of the board of directors and that the Home Care Organization’s operation is
governed by the laws and regulations that are enforced by the Department.
All members of the board of directors and prospective members of the board are required to read, complete, and sign the
statement below as a condition of licensure.
I have read and understand my legal duties and obligations as a member or prospective member of the board of directors
and I also understand that the Home Care Organization’s operation is governed by laws and regulations that are enforced
by the California Department of Social Services.
Note: Boards of directors should ensure that they are informed of law and regulation changes.
HCS 9165 (8/15)
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