Form Hcs 001 - Home Care Organization Suboffice Request

Download a blank fillable Form Hcs 001 - Home Care Organization Suboffice Request 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 Hcs 001 - Home Care Organization Suboffice Request 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

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HOME CARE SERVICES BUREAU
HOME CARE ORGANIZATION SUBOFFICE REQUEST
This form must be completed by all Home Care Organizations who wish to operate a suboffice. One form must be submitted for each suboffice
location. A suboffice is defined in Section 90-000(s)(5) of the written directive and the administrative responsibilities are outlined in Section 90-
030. If more space is required, attach additional sheet and please type or print clearly. For instructions on how to complete this form, refer to
page two.
REQUEST TYPE
I
I
I
I
Initial
Renewal
Change of Ownership
Update
A. HOME CARE ORGANIZATION INFORMATION
CITY
B. SUBOFFICE INFORMATION
CITY
STREET ADDRESS
OPERATING DAYS AND OPERATING HOURS (no more than 24 hours within a seven calendar-day period)
C. SUBOFFICE DESIGNEE
D. QUESTIONS (if more space is needed, please attach a separate sheet.)
1. What is the primary purpose for the suboffice?
2. How will the Home Care Organization ensure the following:
a. No full-time staff
b. No permanently stored records with confidential client and/or Home Care Aide information
I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS FORM ARE CORRECT TO
THE BEST OF MY KNOWLEDGE
COUNTY WHERE SIGNED
DATE
HOME CARE ORGANIZATION LICENSEE SIGNATURE
HCS 001 (12/15)
PAGE 1 OF 2

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2