Form HCS281 "Application Instructions for a Home Care Organization License" - California

What Is Form HCS281?

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 August 1, 2015;
  • 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;

Download a printable version of Form HCS281 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 HCS281 "Application Instructions for a Home Care Organization License" - California

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Application Instructions for
A Home Care Organization License
Community Care Licensing Division
Home Care Services Bureau
HCS 281 (8/15)
Application Instructions for
A Home Care Organization License
Community Care Licensing Division
Home Care Services Bureau
HCS 281 (8/15)
Community Care Licensing Division
Home Care Services Bureau
Application Booklet for a Home Care Organization License
INTRODUCTION
These instructions are intended to help you file an application for a Home Care Organization license. Attached are
the instructions for filing the application. Before a license can be issued, the California Department of Social
Services (CDSS) must review the information to ensure that you meet the minimum requirements for a license.
The application fee and all Section A and Section B documents must be completed and sent to CDSS as a packet.
The application fee is non-refundable. The processing of your application cannot begin until all the forms are filed
with CDSS. The page entitled “Section A” has links that will take you directly to each licensing form. If you need
additional forms, please visit our website at www.ccld.ca.gov or contact the Home Care Services Bureau. Utilizing
and printing the forms via the website ensures that you are using the most current licensing form.
Submit all Section A and Section B documents in the same sequence as they are listed in this application booklet. If
the forms are incomplete, CDSS will return the entire packet to you. To prevent delays, be sure that you have all the
necessary information completed, properly signed with original signatures, and dated. Please ensure that you make
a photocopy of your application packet before you send to CDSS.
SUBMITTING INSTRUCTIONS
When making payment, please send a check or money order payable to the California Department of Social
Services. To guarantee proper credit of your payment, please ensure that your Home Care Organization number is
listed on the check or money order. Please send your payment, application package and all supporting documents
to the California Department of Social Services, Home Care Services Bureau at:
California Department of Social Services
Home Care Services Bureau
M.S. T8-3-90
744 P Street
Sacramento, CA 95814
Please ensure that you keep a copy of the application package in your administration files.
An application is not considered complete and review of your application cannot commence until the
application package, supporting documents, and payment is received by the California Department of
Social Services.
REGULATIONS
Regulations are currently being developed. Written Directives will be released on or before January 1, 2016.
INFORMATION PRACTICE ACT: This information is requested by the Department of Social Services in compliance with Title 22,
Division 6 of the California Code of regulations and Section 1796 et. seq. of Health and Safety Code. Submission of the information is
mandatory. The Department is responsible for maintaining the information. Access to this information will be provided unless prohibited
by the Information Practice Act of 1977. Certain authorized public and private agencies may have access to this information including
county Welfare Departments, Department of Justice, Regional Centers, the Department of Developmental Services and the Department
of Mental Health.
PAGE 2 OF 16
Section A
The table below outlines the forms required to be completed by the applicant for initial licensure. These instructions
do not need to be returned with the completed application package.
HOME CARE ORGANIZATION
LICENSING FORMS
CLICK BELOW TO ACCESS EACH FORM
Section
Title of Form
A1.
Application for a Home Care Organization License (HCS 200)
A2.
Licensee Applicant Information (HCS 215)
A3.
Designation of Home Care Organization Responsibility (HCS 308)
A4.
Partnership/Corporation/Limited Liability Company Organization Structure (HCS 309)
A5.
Employee Dishonesty Bond (HCS 402)
A6.
Criminal Record Statement (LIC 508)
A7.
Board of Directors Statement (HCS 9165)
PAGE 3 OF 16
A1. HCS 200 – APPLICATION FOR A HOME CARE ORGANIZATION LICENSE
Ensure that the form is filled out completely and please type or print clearly.
Form instructions are below:
1. Applicant(s): Enter the names of the person(s) or organization legally responsible for the Home Care
Organization. Enter full names (Individuals enter first, middle name, and last name). If filing a joint
application, please ensure that all applicants sign the HCS 200.
2. Requested Action: Check appropriate box.
3. Applicant Mailing Address: Enter legal home mailing address of individual(s) and headquarters mailing
address of corporations. Major partner enters principal business mailing address. Other partner(s) enter
principal business mailing address(es) on Home Care Organization Licensee Applicant Information (HCS
215). Enter the area code with telephone number.
4. Application Filed By: Check appropriate box.
5. Home Care Organization Name: Enter the name used to designate the Home Care Organization in this
application.
6. Home Care Organization Street Address: Enter the physical location of the Home Care Organization. If
applicant(s) has more than one Home Care Organization, a separate application must be completed for
each Home Care Organization. Enter the area code with telephone number.
7. Home Care Organization Mailing Address: Enter the address where the Home Care Organization will
receive all mail sent from the Department.
8. Designee of the Home Care Organization: Enter the name and title of person who will act as the authorized
person of the Home Care Organization to act in the licensee’s absence. This person should match a person
listed on the Designation of Home Care Organization Responsibility (HCS 308).
9. Total Number of Home Care Aides: Enter the total number of Home Care Aides that the Home Care
Organization anticipates to hire. If applying prior to January 1, 2016, enter the total number of Home Care
Aides currently on staff with Home Care Organization.
10. Business Office Hours: Enter days and hours that the Home Care Organization is open to the public.
11. Property Ownership: Check the appropriate box.
11a.
Control of Property: If applicant(s) is leasing or renting, enter name, address and telephone number
of the owner of Home Care Organization premises.
12. Was this Home Care Organization Previously Licensed?: Check YES or NO. If yes, enter the Home Care
Organization name and license number.
13. Other Facilities: Enter the facility name and number of 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 currently operating.
14 - 17. Statement of Home Care Organization Applicant(s)/Home Care Organization Licensee(s)
responsibilities of compliance with all applicable laws and regulations and the signatures of all applicants or
authorized person(s). (i.e., General Partners of a Partnership and Chief Executive Officer or Duly
Authorized Representative for all Corporations, Public Agencies, etc. )
PAGE 4 OF 16
All applicants must sign the application, including each general partner.
Signatures should match the applicant’s name, unless the application is a Corporation or Limited Liability
Company.
If a Corporation is applying for license, all persons signing the application must be authorized by the Board
Resolution and the Board Resolution must be submitted with this form.
If the application indicates that the applicant previously held a license for a facility, CDSS will compare the
Applicant Information Form (HCS 215) and verify that the applicant is not subject to disciplinary action.
NOTE: For Partnerships, Corporations and Limited Liability Companies, please see Section B1 criteria for
additional information.
A2. HCS 215 – HOME CARE ORGANIZATION LICENSEE APPLICANT INFORMATION
Each applicant must complete a HCS 215 form.
If more space is needed for any question, please attached additional sheet.
As specified in Health and Safety Code Section 1796.40, if the applicant previously held a license, held a 10
percent or more beneficial ownership interest, or was an administrator, general partner, corporate officer, or
director of a licensed facility, CDSS will research to determine if the applicant is subject to disciplinary action.
Form instructions are below:
o
Identifying Information
1. Name: Enter the names of the person(s) or organization legally responsible for the Home Care
Organization. Enter full names (Individuals enter first, middle name, and last name).
i.
Individuals, each general partner, and Chief Executive Officer or authorized representative of a firm,
association, corporation, county, city, public agency or governmental entity must complete Licensee
Applicant Information Form (HCS 215). Corporations and other organizations also complete the
Partnership/Corporation/Limited Liability Company Organization Structure (HCS 309).
2. Social Security Number: Enter the Social Security Number of the individual. This is voluntary and for
identification purposes only.
3. Sex: Enter ‘M’ for Male or “F” for Female.
4. Date of Birth: Enter the birthday of the individual in MM/DD/YYYY format.
5. Title: Enter the individual’s title held within the Home Care Organization.
6. Driver’s License Number/Identification Card Number: Enter either the driver’s license number or
identification card number of the individual.
7. State Issued: Enter the state where either the driver’s license number or identification card number was
issued.
8. Alien Registration Card Number: If the individual holds an alien registration card rather than a state
issued driver’s license or identification card, enter the alien registration card number.
9. Home Address: Enter legal home address of individual.
PAGE 5 OF 16