Form Fcr 16 - Group Home/short Term Residential Therapeutic Program (Strtp) Shelter Costs Declaration And Survey Page 2

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State of California – Health and Human Services Agency
California Department of Social Services
PART II
FACILITY INFORMATION SHEET
Please complete this Facility Information Sheet with related license and location details.
Licensee/NPO Name: _________________________________________________________________
Program Number: (new provider leave blank) _______________________________________________
Please list below the community care license number and street address for each facility that you have
identified in Part I, line 1, and any office space you have identified on line 4:
1. License No.:
________________________
2. License No.:
________________________
Lessor Name: ________________________
Lessor Name: ________________________
Address:
________________________
Address:
________________________
City, State:
________________________
City, State:
________________________
Type of Property
line 2
, line 3a
,
Type of Property
line 2
, line 3a
,
from Part I:
line 3b
, or line 4
from Part I:
line 3b
, or line 4
3. License No.:
________________________
4. License No.:
________________________
Lessor Name: ________________________
Lessor Name: ________________________
Address:
________________________
Address:
________________________
City, State:
________________________
City, State:
________________________
Type of Property
line 2
, line 3a
,
Type of Property
line 2
, line 3a
,
from Part I:
line 3b
, or line 4
from Part I:
line 3b
, or line 4
5. License No.:
________________________
6. License No.:
________________________
Lessor Name: ________________________
Lessor Name: ________________________
Address:
________________________
Address:
________________________
City, State:
________________________
City, State:
________________________
Type of Property
line 2
, line 3a
,
Type of Property
line 2
, line 3a
,
from Part I:
line 3b
, or line 4
from Part I:
line 3b
, or line 4
7. License No.:
________________________
8. License No.:
________________________
Lessor Name: ________________________
Lessor Name: ________________________
Address:
________________________
Address:
________________________
City, State:
________________________
City, State:
________________________
Type of Property
line 2
, line 3a
,
Type of Property
line 2
, line 3a
,
from Part I:
from Part I:
line 3b
, or line 4
line 3b
, or line 4
If additional space is needed, you may duplicate this survey sheet.
FCR 16 (10/17)
Page 2 of 4

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