Form Lic606 "Residential Care Facility for the Elderly Disclosure Worksheet" - California

Form LIC606 is a California Department of Social Services form also known as the "Residential Care Facility For The Elderly Disclosure Worksheet". The latest edition of the form was released in April 1, 2016 and is available for digital filing.

Download an up-to-date fillable Form LIC606 in PDF-format down below or look it up on the California Department of Social Services Forms website.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RESIDENTIAL CARE FACILITY FOR THE ELDERLY DISCLOSURE WORKSHEET
Instructions: This worksheet is optional and designed to assist all RCFE applicants, co-applicants and licensees to
comply with the disclosure requirements outlined in AB 601 (Chapter 628, Statutes of 2015), which amended Health and
Safety Code (HSC) Sections 1569.2, 1569.15, 1569.16, 1569.50, 1569.58, and 1569.618 and added 1569.356.
You may photocopy this worksheet if necessary. Please label all copies and attached documents clearly.
Name of Facility:
License number (if applicable):
Name of Applicant/Co-applicant/Licensee/Co-licensee:
Name of individual submitting this information:
Date worksheet submitted:
Part 1. General Information HSC 1569.15(a)(3), 1569.15(e)
a. This information is submitted as an:
(check one)
I
I
Addendum to an application
Update to a licensed facility's information
(If updating, review Part 10., before completing worksheet.)
b. State type of provider:
(check one)
I
I
For-profit provider
Not-for-profit provider
c. Provide the email address of record for the facility here: _____________________________________________
P
art 2. Evidence of Reputable and Responsible Character HSU 1569.15(a)(2), 1569.15(a)(3)(B)
a. All individuals and entities holding a beneficial ownership interest of 10 percent or more, and/or with operational control
of the facility are required to provide evidence regarding reputable and responsible character.
(Note: Individuals and entities with operational control of the facility, must also disclose information in Parts 5., 6. and
7.)
b. Separate list is attached giving the names, addresses and phone numbers of the individuals
Yes
No
I
I
and entities who hold a 10 percent beneficial ownership in the applicant or co-applicant.
c. Separate list is attached disclosing the names, addresses and phone numbers of individuals
I
I
or entities who have operational control of the applicant or licensee.
Yes
No
Operational control involves control over the daily operation of the facility. Examples of individuals and entities with
operational control may include, but are not limited to: (1) administrator; (2) owner; (3) Chief Executive Officer or
Executive Director; (4) general partner; (5) like party who is in charge of daily operations of a facility; and/or,
(6) parent organization.
d. For each individual identified in the lists called for above in Parts 2.b. and 2.c., please verify the following:
I
I
(1) Criminal record statements were submitted (Form 508);
Yes
No
I
I
(2) Fingerprints and Form 9163 were submitted; and,
Yes
No
I
I
(3) Employment history and character references were submitted (Form LINC 215).
Yes
No
Note: It may take time to receive a criminal records clearance, it is advised that fingerprints be submitted as early as
possible.
LIC 606 (4/16)
PAGE 1 OF 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RESIDENTIAL CARE FACILITY FOR THE ELDERLY DISCLOSURE WORKSHEET
Instructions: This worksheet is optional and designed to assist all RCFE applicants, co-applicants and licensees to
comply with the disclosure requirements outlined in AB 601 (Chapter 628, Statutes of 2015), which amended Health and
Safety Code (HSC) Sections 1569.2, 1569.15, 1569.16, 1569.50, 1569.58, and 1569.618 and added 1569.356.
You may photocopy this worksheet if necessary. Please label all copies and attached documents clearly.
Name of Facility:
License number (if applicable):
Name of Applicant/Co-applicant/Licensee/Co-licensee:
Name of individual submitting this information:
Date worksheet submitted:
Part 1. General Information HSC 1569.15(a)(3), 1569.15(e)
a. This information is submitted as an:
(check one)
I
I
Addendum to an application
Update to a licensed facility's information
(If updating, review Part 10., before completing worksheet.)
b. State type of provider:
(check one)
I
I
For-profit provider
Not-for-profit provider
c. Provide the email address of record for the facility here: _____________________________________________
P
art 2. Evidence of Reputable and Responsible Character HSU 1569.15(a)(2), 1569.15(a)(3)(B)
a. All individuals and entities holding a beneficial ownership interest of 10 percent or more, and/or with operational control
of the facility are required to provide evidence regarding reputable and responsible character.
(Note: Individuals and entities with operational control of the facility, must also disclose information in Parts 5., 6. and
7.)
b. Separate list is attached giving the names, addresses and phone numbers of the individuals
Yes
No
I
I
and entities who hold a 10 percent beneficial ownership in the applicant or co-applicant.
c. Separate list is attached disclosing the names, addresses and phone numbers of individuals
I
I
or entities who have operational control of the applicant or licensee.
Yes
No
Operational control involves control over the daily operation of the facility. Examples of individuals and entities with
operational control may include, but are not limited to: (1) administrator; (2) owner; (3) Chief Executive Officer or
Executive Director; (4) general partner; (5) like party who is in charge of daily operations of a facility; and/or,
(6) parent organization.
d. For each individual identified in the lists called for above in Parts 2.b. and 2.c., please verify the following:
I
I
(1) Criminal record statements were submitted (Form 508);
Yes
No
I
I
(2) Fingerprints and Form 9163 were submitted; and,
Yes
No
I
I
(3) Employment history and character references were submitted (Form LINC 215).
Yes
No
Note: It may take time to receive a criminal records clearance, it is advised that fingerprints be submitted as early as
possible.
LIC 606 (4/16)
PAGE 1 OF 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
3. Other Facilities HSC 1569.15(a)(3)(C)-(D), 1569.15(a)(3)(B)
a. Facilities: Provide information for all other health, residential or community care facilities owned, managed or operated
by the applicant, licensee, and/or management company located anywhere in the United States.
I
I
(1)
Do you have other such facilities?
Yes
No
( (2)
If yes, a separate list of facilities is attached including facility name, address,
I
I
license number, licensing agency, and relationship to this applicant/licensee.
Yes
No
b. Parent Organizations: Provide information for all other health, residential or community care
facilities owned, managed or operated by parent organizations of the applicant, licensee,
and/or management company, and/or parent organizations of the parent organizations, etc.,
located in California or any other state.
I
I
(1)
Do parent organizations have other such facilities?
Yes
No
(2)
If yes, a separate list of facilities is attached including facility name, address, license
I
I
number, licensing agency, and relationship to this applicant/licensee.
Yes
No
Part 4. Real Property Owners and Right to Possession HSC 1569.15(a)(3)(E)
a. Attach the following information about the owners of real property:
Yes
No
I
I
(1) Separate list is attached with names and addresses of the owners of the real property for
this facility.
Yes
No
I
I
(2) Separate list is attached with names and addresses of the owners of the real property for
all other facilities identified in Parts 3.a. and 3.b.
b. Evidence is attached showing right to possession of the facility, including the real property
Yes
No
I
I
deed and all lease and sublease agreements.
Part 5. Individuals and/or Entities with Operational Control HSC 1569.15(a)(5)
a Each applicant/licensee and each individual or entity identified as having operational control in response to Part 2.c.
above must provide information regarding prior and present service in any RCFE, clinic, health facility, community care
facility, or similarly licensed facility, in California or any other state within the past 10 years.
Yes
No
I
I
b. Separate list is attached providing the information regarding prior or present service about the
applicant/licensee and iNdividuals and entities with operational control of the facility:
(1) Name, title(s), and address of the individual or entity that controls the applicant or licensee;
(2) Name of facility, license number, and name of licensing agency; and,
(3) Dates of service in that role or roles at the facility.
LIC 606 (4/16)
PAGE 2 OF 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Part 7. Bankruptcy Filings HSC 1569.16(a)(6)(C)
a. Any individual or entity identified in Part 5. above must report information regarding filings for bankruptcy relief which
meet all of the following criteria:
(1) The bankruptcy filing involved the operation or closure of a health, residential, or community care facility;
(2) which is/was licensed in California or any other state,
(3) by an applicant, or by an individual or entity with operational control (identified in Part 2.b),
(4) within the 5 years prior to the date of application for applicants, or within 30 days of filing for bankruptcy
for licensees.
I
I
Do you have any bankruptcy filings which meet the criteria in Part 7.a.?
Yes
No
If yes, answer Part 7.b. If no, skip to Part 8.
I
I
b. A list is attached disclosing bankruptcy filings matching the criteria, including:
Yes
No
(1) Name of the applicant or individual or entity with operational control (identified in Part 2.b.);
(2) Name of the court in which the action is filed;
(3) Case number;
(4) Date filed;
(5) Current status of case, including whether a discharge has or has not been granted; and,
(6) Attach copies of related documents, including: documents filed, court findings, and
I
I
documents supporting discharge or denial of discharge.
Yes
No
PAG 3 OF 5
LIC 606 (4/16)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Part 8. Chains of Licensees HSC 1569.15(a)(3)(D)
a. A facility is part of a "chain" when an applicant or licensee is part of a group of two or more licensees whose operation
or management is controlled and/or directed by the same individuals or entities.
b. When updating information, a licensee of multiple facilities (a chain) may provide a single notice of changes to
DSS that clearly states it is on behalf of all licensed facilities within a chain. Such notice should include names, license
numbers, and licensee names of the facilities it covers.
I
I
c. Is this facility's applicant or licensee part of a chain?
Yes
No
If yes, attach the following information as separate sheets. If no, skip to Part 9.
I
I
(1) A diagram is attached indicating the relationship between the applicant and/or licensee,
Yes
No
and the individuals and/or entities that are part of the chain including percentages of
ownership; and,
Yes
No
I
I
(2) A separate sheet is attached providing the name, address, license number if any, and
the percentage of ownership for each individual and entity in the diagram.
Part 9. Management Companies HSC 1569.15(a)(3)(C)-(F)
a. Does the applicant or licensee include a management company serving the facility as co-licensee?
I
I
Yes
No
Yes
No
I
I
If yes, provide the following information on separate sheets, if it has not already been provided
above. If no, skip to Part 10.
(1) Name and address of any management company serving the facility; and,
(2) Name and address of any person that has operational control of the management company
I
I
b. Is the management company part of a chain?
Yes
No
If yes, attach the following information as separate sheets, if it has not already been provided
above. If no, skip to Part 10.
Yes
No
I
I
(1) A diagram is attached indicating the relation between the management company and the
individuals and/or entities that are part of the chain including percentages of ownership; and,
Yes
No
I
I
(2) A separate sheet is attached providing the name, address, and license number if any,
for each individual and/or entity in the diagram.
LIC 606 (4/16)
PAGE 4 OF 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Part 10. Updating Information due to Changes HSC 1569.15(d)(1)-(2)
You may use this worksheet to notify DSS of any changes in information in currently licensed facilities.
a. Licensees are required to abide by the new disclosure requirements on a flow basis, specific to any change that occurs
on or after January 1, 2016. When a change occurs, licensees must provide updates to information to DSS within 30
calendar days unless a different timeframe is required by statute or regulation.
b. Information pertaining to facilities operating outside California may be updated annually on or before December 31st of
each calendar year, except in the following instances where a shorter time period applies:"
(1) Administrative disciplinary actions and bankruptcies must be updated within 30 calendar days after the change.
Complete Part 6. and/or Part 7., above.
(2) Other facilities and parent organizations must be updated within 6 months after the change. Complete Part 3.,
above.
c. If there is a change in information identified on this worksheet that was not previously reported to DSS, sufficient
information should be provided by the licensee to allow DSS to understand the context of the change.
d. A licensee of multiple facilities (a chain) may provide a single notice of changes to DSS that clearly states it is on behalf
of all licensed facilities within a chain. Such notice should include names, license numbers, and licensee names of the
facilities it covers.
e. Where to send updated information:
(1) If your updates pertain to an application that is pending, for which a license has not yet been issued, send the
updates to the Analyst handling your application to: Centralized Applications Unit, 744 P Street, MS 8-3-91,
Sacramento, CA 95814.
(2) If your updates pertain to a facility which is already licensed, send the updates to the Regional Office where the
facility is located. See www.ccld.ca.gov/res/pdf/ASC.pdf for Regional Office contact information.
Part 11. Notice regarding Actions CDSS may take now for Failure to Disclose Required Information HSC
1569.15(f)(1)-(3)
a. If an applicant or licensee fails to disclose full and complete information within the timeframes specified by existing law
and the changes made by AB 601 (Chapter 628, Statutes of 2015), CDSS has additional remedies.
(1) CDSS may deny an application for licensure or may subsequently revoke a license if the applicant:
(a) Knowingly withheld material information or made a false statement of material fact in the information provided.
(b) Did not disclose administrative disciplinary actions on the application as required under Part 6.a., above.
(2) In addition to any other remedies provided, DSS may, subsequent to licensure, assess a civil penalty of one
thousand dollars ($1,000) for a material violation of the disclosure requirements.
LIC 606 (4/16)
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