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Form Dhcs 5085 - California Designation Of Administrative Responsibility - Health And Human Services Agency

State of California — Health and Human Services Agency

Department of Health Care Services

Licensing and Certification Branch, MS 2600

PO Box 997413

Sacramento, CA 95899-7413

A-4 – DESIGNATION OF ADMINISTRATIVE RESPONSIBILITY

Applicants who are corporations shall attach board resolutions authorizing a delegation to the Program

Director and/or Administrator or other appropriate staff.

Applicant Name:

Program Name:

Program Address:

City:

County:

Zip Code:

Telephone: (

)

E-mail Address:

(Name of person(s) authorized by applicant)

is hereby designated as administrator, program manager, or agent of the above-named program and is

authorized to receive at the above named program on my behalf, any documents including reports of

inspections and consultations, accusations, and civil and administrative processes.

PER SECTION 10561(C)(3), I WILL NOTIFY THE DEPARTMENT OF HEALTH CARE SERVICES, WITHIN 10

WORKING DAYS OF ANY CHANGE OF THE ADMINISTRATOR OF THE FACILITY.

Signature of applicant(s)

Title:

Address:

10.

City:

County:

Zip Code:

DHCS 5085 (06/13)

Form Dhcs 5085 - California Designation Of Administrative Responsibility - Health And Human Services Agency