Form HCS200 "Application for a Home Care Organization License" - California

What Is Form HCS200?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2020;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HCS200 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form HCS200 "Application for a Home Care Organization License" - California

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State of California – Health and Human Services Agency
Community Care Licensing Division
California Department of Social Services
Home Care Services Bureau
APPLICATION FOR A HOME CARE ORGANIZATION LICENSE
For instructions on how to complete this form, please refer to the HCS 281, available on our website,
ccld.ca.gov.
Home Care Organization Number (If Known)
County
1. Applicant(s) Name(s) (Please Print)
2. Requested Action (Check One)
A. Initial Application
________________________________________
B. Application Renewal
________________________________________
C. Change Of Location
________________________________________
D. Change Within Corporation
E. Sale
F. Other (Specify)
3. Applicant Mailing Address
City
State
Zip Code Licensee Phone
(
)
4. Application Filed By:
A. Individual
B. Partnership
C. Non Profit Corporation
D. Profit Corporation
E. County
F. Other Public Agency
G. Limited Liability Company
5. Home Care Organization Name
Email Address
HCO Phone
(
)
6. Home Care Organization Street Address
City
County
Zip Code Alt. Public Phone
(
)
7. Home Care Organization Mailing Address City
State
Zip Code
8. Designee Of Home Care Organization
Title
9. Business Office Hours
10. Property Ownership
Own
Rent
Other (Specify)
10A. Name, Address and Phone Number of Property Owner, If Renting or Leasing
11. Was this Home Care Organization
If yes, Home Care Organization name and license number
previously licensed?
Yes
No
HCS 200 (2/20)
Page 1 of 2
State of California – Health and Human Services Agency
Community Care Licensing Division
California Department of Social Services
Home Care Services Bureau
APPLICATION FOR A HOME CARE ORGANIZATION LICENSE
For instructions on how to complete this form, please refer to the HCS 281, available on our website,
ccld.ca.gov.
Home Care Organization Number (If Known)
County
1. Applicant(s) Name(s) (Please Print)
2. Requested Action (Check One)
A. Initial Application
________________________________________
B. Application Renewal
________________________________________
C. Change Of Location
________________________________________
D. Change Within Corporation
E. Sale
F. Other (Specify)
3. Applicant Mailing Address
City
State
Zip Code Licensee Phone
(
)
4. Application Filed By:
A. Individual
B. Partnership
C. Non Profit Corporation
D. Profit Corporation
E. County
F. Other Public Agency
G. Limited Liability Company
5. Home Care Organization Name
Email Address
HCO Phone
(
)
6. Home Care Organization Street Address
City
County
Zip Code Alt. Public Phone
(
)
7. Home Care Organization Mailing Address City
State
Zip Code
8. Designee Of Home Care Organization
Title
9. Business Office Hours
10. Property Ownership
Own
Rent
Other (Specify)
10A. Name, Address and Phone Number of Property Owner, If Renting or Leasing
11. Was this Home Care Organization
If yes, Home Care Organization name and license number
previously licensed?
Yes
No
HCS 200 (2/20)
Page 1 of 2
State of California – Health and Human Services Agency
California Department of Social Services
12. If currently operating any community care facility, residential care facility, residential care facility
for the elderly, residential care facility for persons with chronic life-threatening illness, child day
care facility, day care center, family day care home, employer-sponsored child care center, or
home care organization, please enter the information below:
Facility/Home Care Organization Name
Facility/Home Care Organization Number
A.
B
C.
D.
13. Home Care Organization applicant(s)/Home Care Organization licensee(s) responsibilities:
a. In addition to complying with the health and safety codes and regulations applicable to
licensing. I/we understand that there may be other state, federal and/or local laws, which are
not enforced by this department that may need to be met such as: zoning, building, sanitation
and labor requirements.
b. I/we have read and understand the statutes, written directives and/or regulations which pertain
to my/our licensing category prior to the issuance of my/our license.
c. I/we shall ensure that all persons subject to fingerprint requirements shall have a California
department of justice clearance or a criminal record exemption prior to employment, residence
or initial presence in the organization as required.
d. I/we shall obtain approval from the department prior to making any change(s) that affects the
terms of the license.
14. I/we understand that i/we have the right to appeal any decision regarding the disposition of this
application.
15. I/we declare under penalty of perjury that the statements on this application and on the
accompanying attachments are correct to the best of my/our knowledge.
16. I/we am/are authorized to sign this application on behalf of the named applicant.
Signed
Title
County Where Signed
Date
Signed
Title
County Where Signed
Date
Signed
Title
County Where Signed
Date
HCS 200 (2/20)
Page 2 of 2
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