Form Dhcs 5112 - California Initial Certification Application - Health And Human Services Agency Page 11
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11STATE 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
9.
Nondiscrimination in the Provision of Services – Written assurance that programs shall not
discriminate in the provision of services on the basis of ethnic group identification, religion, age, sex, color,
or disability, pursuant to Title VI of the Civil Rights Act of 1964 (Section 2000, Title 42, United States
Code), The Rehabilitation Act of 1973 (Section 794, Title 29, United States Code); The Americans with
Disabilities Act of 1990 (Section 12132, Title 42, United States Code); Section 11135 of the California
Government Code; and Chapter 6 (commencing with Section 10800), Division 4, Title 9 of the California
Code of Regulations. [Standards Section 3035 a. 9.]
10.
A Copy of the Program’s Participant Admission Agreement – The admission agreement shall inform
the participant of the following: [Standards Section 3035 a. 10.]
a.
Fees assessed for services provided;
b.
Activities expected of participant;
c.
Program rules and regulations;
d.
Participants’ statutory rights to confidentiality;
e.
Participants’ grievance procedure; and
f.
Reasons for termination.
11.
Table of Administrative Organization – A document showing the lines of authority of all paid and
volunteer staff including the board of directors (if applicable) and the community advisory board. Public
organizations shall provide an organization chart that reflects the program's placement within a
government agency. Private organizations shall provide documentation of the legal authority for the
formation of the agency. [Standards Section 3035 a. 11.]
12.
Job Description, and Minimum Staff Qualification – Staff job descriptions and the minimum staff
qualifications for the positions. [Standards Section 3035 a. 12.]
13.
An Approved Fire Clearance – Documentation of the most recent fire safety inspection by the local fire
authority (no more than 12 months prior to the date that the Department receives the application for
certification) assuring that all fire safety requirements have been met. [Standards Section 3035 b.]
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14.
Copy of a State Facility License – (this only applies to residential facilities that are not licensed by
DHCS) [Standards Section 3015]
15.
Partnership Agreement/Articles of Incorporation/Bylaws – If the applicant is a corporation or
association, the following information is required [Standards Section 3030 a. 2. B.]:
a.
A copy of the Articles of Incorporation signed and dated by the Secretary of State.
b.
A copy of the By-Laws.
DHCS Form 5082 – Administrator or Director Information.
c.
DHCS Form 5083 (Corporations) or 5084 (Public Agencies, Partnerships, Sole Proprietor, and
d.
Other Associations) – Administrative Organization.
DHCS Form 5085 – Designation of Administrative Responsibility
e.
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16.
Sole Proprietors – If the applicant is a sole proprietor, please complete, sign, and return a completed
Statement of Citizenship, Alienage, and Immigration Status for State Public Benefits with your
completed application.
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Page 11 of 11
DHCS 5112 (07/13)
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