Form LIC200 "Application for a Community Care Facility or Residential Care Facility for the Elderly License" - California

What Is Form LIC200?

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, 2011;
  • 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 LIC200 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 LIC200 "Application for a Community Care Facility or Residential Care Facility for the Elderly License" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICATION FOR A COMMUNITY CARE FACILITY OR RESIDENTIAL CARE FACILITY
FOR THE ELDERLY LICENSE
(See Instructions on next page)
REPLY TO:
FOR DEPARTMENT USE ONLY
DISTRICT:
COUNTY:
FACILITY NUMBER:
DATE:
ACTION TYPE:
REVIEWED BY:
FACILITY TYPE:
1.
APPLICANT(S) NAME(S) (PLEASE PRINT)
2. REQUESTED ACTION (CHECK ONE):
A. INITIAL APPLICATION
E. CHANGE OF AMB/NON-
B. CHANGE OF CAPACITY
AMB BEDRIDDEN STATUS
C. CHANGE OF LOCATION
F. CHANGE WITHIN CORPORATION
D. CHANGE OF FACILITY TYPE
G. OTHER (Specify)
3.
APPLICANT MAILING ADDRESS
CITY
STATE
ZIP CODE
AREA CODE/TELEPHONE
(
)
4.
TYPE OF AGENCY OR FACILITY
ADULT RESIDENTIAL FACILITIES
SOCIAL REHABILITATION FACILITIES
RESIDENTIAL FACILITIES--ELDERLY
FOSTER FAMILY AGENCIES
ADOPTION AGENCIES
RESIDENTIAL FACILITIES--CHRONICALLY ILL
ADULT DAY PROGRAMS
GROUP HOMES
SMALL FAMILY HOMES
TRANSITIONAL HOUSING PLACEMENT PROGRAMS
CRISIS NURSERIES
OTHER( SPECIFY)________________________
5.
APPLICATION
A.
INDIVIDUAL
B.
PARTNERSHIP
C. NON PROFIT CORP.
G. LIMITED LIABILITY
CORPORATION
FILED BY:
D.
PROFIT CORP
E.
COUNTY
F.
OTHER PUBLIC AGENCY
AREA CODE/TELEPHONE
EMAIL ADDRESS (NOT REQUIRED)
6.
FACILITY OR AGENCY NAME
(
)
7.
FACILITY STREET ADDRESS
CITY
COUNTY
ALTERNATIVE PUBLIC
ZIP CODE
TELEPHONE
(
)
8.
FACILITY MAILING ADDRESS
CITY
STATE
ZIP CODE
9.
ADMINISTRATOR OR PERSON IN CHARGE OF FACILITY
TITLE
10B. NUMBER OF BEDRIDDEN UNABLE TO TURN OR REPOSITION
10.
TOTAL REQUESTED CAPACITY
10A.
NUMBER OF NON-AMBULATORY (IF ANY)
IN BED (IF ANY)
11. FOR CHILDREN’S FACILITY ONLY:
NUMBER OF INFANTS (AGES 0 THROUGH 2) ___________
CHILDREN (AGES 3 THROUGH 17) _____________
12.
DAYS AND HOURS OF OPERATION:
13.
PROPERTY OWNERSHIP:
OWN
RENT
OTHER (SPECIFY)
__________________________________________________________________________
13A. NAME, ADDRESS AND PHONE NUMBER OF PROPERTY OWNER, IF RENTING OR LEASING:
14.
WAS FACILITY PREVIOUSLY LICENSED? IF YES, FACILITY NAME AND NUMBER:
LICENSING AGENCY NAME:
YES
NO
15.
IS MAJOR CONSTRUCTION REQUIRED?
16.
SOURCE OF WATER FOR HUMAN CONSUMPTION
DATE CONSTRUCTION TO BEGIN: ______________________________________
YES
NO
PUBLIC
PRIVATE
DATE TO BE COMPLETED:
_________________________________________________
17.
ENTER THE INFORMATION BELOW FOR ANY RESIDENTIAL CARE OR HEALTH CARE FACILITY PREVIOUSLY OR CURRENTLY OPERATED. REFER TO INSTRUCTIONS.
FACILITY NAME AND NUMBER
LICENSING AGENCY NAME
A.
______________________________________________________________________________________________________________________________________________________________________________________
B.
______________________________________________________________________________________________________________________________________________________________________________________
18.
APPLICANT(S)/LICENSEE(S) RESPONSIBILITIES:
A. IN ADDITION TO COMPLYING WITH THE HEALTH AND SAFETY CODES AND REGULATIONS APPLICABLE TO LICENSING AND FIRE SAFETY, I/WE UNDERSTAND THAT THERE MAY BE
OTHER STATE, FEDERAL AND/OR LOCAL LAWS, WHICH ARE NOT ENFORCED BY THIS AGENCY, THAT MAY NEED TO BE MET SUCH AS: ZONING, BUILDING, SANITATION AND LABOR
REQUIREMENTS.
B.
I/WE HAVE READ AND UNDERSTAND THE STATUTES AND 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 DEPARTMENT OF JUSTICE CLEARANCE OR A CRIMINAL RECORD EXEMPTION
PRIOR TO EMPLOYMENT, RESIDENCE OR INITIAL PRESENCE IN THE FACILITY AS REQUIRED.
D. IF I/WE OPERATE A FACILITY WHICH PROVIDES CARE AND SUPERVISION TO CHILDREN. I/WE SHALL ENSURE THAT A CHILD ABUSE INDEX CHECK FORM FOR EACH PERSON SUBJECT TO
FINGERPRINT REQUIREMENTS IS SUBMITTED TO THE DEPARTMENT OF JUSTICE AS REQUIRED.
E. I/WE SHALL OBTAIN APPROVAL FROM THE LICENSING AGENCY PRIOR TO MAKING ANY CHANGE(S) THAT AFFECT THE TERMS OF THE LICENSE.
19.
I/WE UNDERSTAND THAT I/WE HAVE THE RIGHT TO APPEAL ANY DECISION REGARDING THE DISPOSITION OF THIS APPLICATION.
20.
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.
21.
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
LIC 200 (2/11) PUBLIC
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICATION FOR A COMMUNITY CARE FACILITY OR RESIDENTIAL CARE FACILITY
FOR THE ELDERLY LICENSE
(See Instructions on next page)
REPLY TO:
FOR DEPARTMENT USE ONLY
DISTRICT:
COUNTY:
FACILITY NUMBER:
DATE:
ACTION TYPE:
REVIEWED BY:
FACILITY TYPE:
1.
APPLICANT(S) NAME(S) (PLEASE PRINT)
2. REQUESTED ACTION (CHECK ONE):
A. INITIAL APPLICATION
E. CHANGE OF AMB/NON-
B. CHANGE OF CAPACITY
AMB BEDRIDDEN STATUS
C. CHANGE OF LOCATION
F. CHANGE WITHIN CORPORATION
D. CHANGE OF FACILITY TYPE
G. OTHER (Specify)
3.
APPLICANT MAILING ADDRESS
CITY
STATE
ZIP CODE
AREA CODE/TELEPHONE
(
)
4.
TYPE OF AGENCY OR FACILITY
ADULT RESIDENTIAL FACILITIES
SOCIAL REHABILITATION FACILITIES
RESIDENTIAL FACILITIES--ELDERLY
FOSTER FAMILY AGENCIES
ADOPTION AGENCIES
RESIDENTIAL FACILITIES--CHRONICALLY ILL
ADULT DAY PROGRAMS
GROUP HOMES
SMALL FAMILY HOMES
TRANSITIONAL HOUSING PLACEMENT PROGRAMS
CRISIS NURSERIES
OTHER( SPECIFY)________________________
5.
APPLICATION
A.
INDIVIDUAL
B.
PARTNERSHIP
C. NON PROFIT CORP.
G. LIMITED LIABILITY
CORPORATION
FILED BY:
D.
PROFIT CORP
E.
COUNTY
F.
OTHER PUBLIC AGENCY
AREA CODE/TELEPHONE
EMAIL ADDRESS (NOT REQUIRED)
6.
FACILITY OR AGENCY NAME
(
)
7.
FACILITY STREET ADDRESS
CITY
COUNTY
ALTERNATIVE PUBLIC
ZIP CODE
TELEPHONE
(
)
8.
FACILITY MAILING ADDRESS
CITY
STATE
ZIP CODE
9.
ADMINISTRATOR OR PERSON IN CHARGE OF FACILITY
TITLE
10B. NUMBER OF BEDRIDDEN UNABLE TO TURN OR REPOSITION
10.
TOTAL REQUESTED CAPACITY
10A.
NUMBER OF NON-AMBULATORY (IF ANY)
IN BED (IF ANY)
11. FOR CHILDREN’S FACILITY ONLY:
NUMBER OF INFANTS (AGES 0 THROUGH 2) ___________
CHILDREN (AGES 3 THROUGH 17) _____________
12.
DAYS AND HOURS OF OPERATION:
13.
PROPERTY OWNERSHIP:
OWN
RENT
OTHER (SPECIFY)
__________________________________________________________________________
13A. NAME, ADDRESS AND PHONE NUMBER OF PROPERTY OWNER, IF RENTING OR LEASING:
14.
WAS FACILITY PREVIOUSLY LICENSED? IF YES, FACILITY NAME AND NUMBER:
LICENSING AGENCY NAME:
YES
NO
15.
IS MAJOR CONSTRUCTION REQUIRED?
16.
SOURCE OF WATER FOR HUMAN CONSUMPTION
DATE CONSTRUCTION TO BEGIN: ______________________________________
YES
NO
PUBLIC
PRIVATE
DATE TO BE COMPLETED:
_________________________________________________
17.
ENTER THE INFORMATION BELOW FOR ANY RESIDENTIAL CARE OR HEALTH CARE FACILITY PREVIOUSLY OR CURRENTLY OPERATED. REFER TO INSTRUCTIONS.
FACILITY NAME AND NUMBER
LICENSING AGENCY NAME
A.
______________________________________________________________________________________________________________________________________________________________________________________
B.
______________________________________________________________________________________________________________________________________________________________________________________
18.
APPLICANT(S)/LICENSEE(S) RESPONSIBILITIES:
A. IN ADDITION TO COMPLYING WITH THE HEALTH AND SAFETY CODES AND REGULATIONS APPLICABLE TO LICENSING AND FIRE SAFETY, I/WE UNDERSTAND THAT THERE MAY BE
OTHER STATE, FEDERAL AND/OR LOCAL LAWS, WHICH ARE NOT ENFORCED BY THIS AGENCY, THAT MAY NEED TO BE MET SUCH AS: ZONING, BUILDING, SANITATION AND LABOR
REQUIREMENTS.
B.
I/WE HAVE READ AND UNDERSTAND THE STATUTES AND 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 DEPARTMENT OF JUSTICE CLEARANCE OR A CRIMINAL RECORD EXEMPTION
PRIOR TO EMPLOYMENT, RESIDENCE OR INITIAL PRESENCE IN THE FACILITY AS REQUIRED.
D. IF I/WE OPERATE A FACILITY WHICH PROVIDES CARE AND SUPERVISION TO CHILDREN. I/WE SHALL ENSURE THAT A CHILD ABUSE INDEX CHECK FORM FOR EACH PERSON SUBJECT TO
FINGERPRINT REQUIREMENTS IS SUBMITTED TO THE DEPARTMENT OF JUSTICE AS REQUIRED.
E. I/WE SHALL OBTAIN APPROVAL FROM THE LICENSING AGENCY PRIOR TO MAKING ANY CHANGE(S) THAT AFFECT THE TERMS OF THE LICENSE.
19.
I/WE UNDERSTAND THAT I/WE HAVE THE RIGHT TO APPEAL ANY DECISION REGARDING THE DISPOSITION OF THIS APPLICATION.
20.
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.
21.
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
LIC 200 (2/11) PUBLIC
PAGE 1 OF 2
INSTRUCTIONS FOR APPLICATION FOR FACILITY LICENSE
Type or print clearly. Prepare application in duplicate. Return original and maintain a copy for your records. Attach to this
application form, a copy of all requested forms and documents including those underlined below.
1.
Applicant(s): Enter the names of the person(s) or organization legally responsible for the facility. Enter full names.
Individuals enter first, middle and last name. If joint application, all applicants must sign this application. 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 Applicant Information (LIC 215). Corporations and other organizations
also complete Administrative Organization, (LIC 309).
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 Applicant Information (LIC 215). Enter area code with telephone number.
4.
Type of Agency or Facility: Check the appropriate box for type of facility as defined in California Code of Regulations, Title
22. If unknown, enter the name commonly used to identify such a facility in space marked “other”.
5.
Application Filed By: Check appropriate box.
6.
Facility or Agency Name: Enter the name used to designate the single facility under application. If an agency, fill in the name
of the agency which provides the services.
7.
Facility Street Address: Enter the physical location of the facility. If applicant has more than one facility, a separate
application must be completed for each facility. Enter area code with telephone number.
8.
Facility Mailing Address: Enter the address where all mail for the facility from the department/licensing agency should be
sent.
9.
Administrator or Person in Charge of Facility: Enter the name and title of person who will directly supervise the facility. If not
yet employed enter “unknown”.
10. Total Requested Capacity: Enter the total number of persons for whom care will be provided in any 24 hour period.
10A. If applicable, enter the number of beds available for non-ambulatory, unable to independently transfer but who do not need
assistance in turning and repositioning in bed.
10B. If applicable, enter the number of beds available for bedridden, unable to independently turn or reposition in bed.
11. For Children’s Facilities Only: Applicants for children’s residential facilities enter the number of infants and the number of
children to be served.
12. Days and Hours of Operation: Enter days and hours of facility operation.
13. Property Ownership: Check the appropriate box.
13a. Control of Property: If applicant(s) is leasing or renting, enter name, address and phone number of owner of facility
premises.
14. Was Facility Previously Licensed?: Check YES or NO. If yes, enter facility name, number and name of agency that issued
license(s).
15. Is Major Construction Required?: Indicate whether or not the facility is to be constructed or requires major structural
improvements. If yes, enter dates construction is to begin and be completed.
16. Source of Water for Human Consumption?: Check PUBLIC or PRIVATE water source.
17. Other Facilities: H & S Code Section 1520(d), 1568.04(b) and 1569.15(d) require that an applicant disclose, prior or present
service as an administrator, general partner,corporate officer or director of, or as a person who has held or holds a beneficial
ownership of 10 percent or more in any community care, residential care facility for chronically ill, residential care facility for
the elderly, or health care facility (attach separate sheet of paper for additional facilities).
18., 19, and 20. Statement of applicant(s)/licensee(s) responsibilities of compliance with all applicable laws and regulations.
21. 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.)
LIC 200 (2/11) PUBLIC
PAGE 2 OF 2
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