Form Dhcs 5112 - California Initial Certification Application - Health And Human Services Agency Page 6
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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
8.
A COPY OF THE ADMISSION, READMISSION, AND
INTAKE CRITERIA
9.
A STATEMENT OF NONDISCRIMINATION IN THE
EMPLOYMENT PRACTICES AND PROVISION OF
BENEFITS AND SERVICES
10. A COPY OF THE PROGRAM’S PARTICIPANT ADMISSION
AGREEMENT
11. A TABLE OF ADMINISTRATIVE ORGANIZATION
12. STAFFING PLAN
13. AN APPROVED FIRE CLEARANCE
14. A COPY OF STATE FACILITY LICENSE
(Residential Only)
15. CORPORATIONS, ASSOCIATIONS, PARTNERSHIPS -
PARTNERSHIP AGREEMENT/ARTICLES OF
INCORPORATION/BYLAWS
16. SOLE PROPRIETORS – STATEMENT OF CITIZENSHIP,
ALIENAGE, AND IMMIGRATION STATUS FOR STATE
PUBLIC BENEFITS
F
D
U
OR
EPARTMENTAL
SE
A
C
: D
:
B
:
PPLICATION
OMPLETE
ATE
Y
DHCS 5112 (07/13)
Page 6 of 11
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