Form Hcs 200a - Intent To Apply For A Home Care Organization License Page 2
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2CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HOME CARE SERVICES BUREAU
APPLICATION INTENT INSTRUCTIONS
Please type or print clearly and ensure that the form is filled out completely.
• Applicant(s): Enter the name(s) of the person(s) or organization legally responsible for the Home Care Organization.
Enter full names (Individuals enter first, middle name, and last name). Please enter the area code with telephone
number of the applicant.
• Applicant Mailing Address: Enter legal mailing address of individual(s), headquarters mailing address of corporations,
and principal business mailing address of major partner(s).
• Application Intent Filed By: Please check the appropriate box.
• Home Care Organization Name: Enter the name used to designate the Home Care Organization under this intent to
apply.
• Home Care Organization Street Address: Enter the physical location of the Home Care Organization. If applicant(s)
has more than one Home Care Organization, a separate intent form must be completed for each Home Care
Organization. Please enter the area code with telephone number of the Home Care Organization.
• Home Care Organization Mailing Address: Enter the address where the Home Care Organization will receive all mail
sent from the Department.
• Alternate Public Telephone: If there is an alternate telephone number for the Home Care Organization, please enter
the area code with telephone number.
• Designee/Representative of the Home Care Organization: If different than the applicant, please enter the name and
title of person who will represent the Home Care Organization in the intent to apply process.
• Total Number of Home Care Aides: Please enter the total number of Home Care Aides currently on staff with the
Home Care Organization. The number of Home Care Aides will be used for projected workload purposes only.
Please note that Home Care Organization applicants who employ Home Care Aides will submit a Home Care Aide registration
list via excel to meet the requirements of California Health and Safety Code Section 1796.61(b). This Home Care Aide
registration list must be submitted to the Home Care Services Bureau electronically on or before December 31, 2015.
PAGE 2 OF 2
HCS 200A (10/15)
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