Cal. Code Regs. Tit. 22, § 87818 - Application for License

(a) Any adult, firm, partnership, association, corporation, county, city, public agency or other governmental entity desiring to obtain a license shall file with the Department a verified application on forms specified below and furnished by the Department:

(1) Application -- LIC 200 (9/87)

(2) Applicant Information -- LIC 215 (8/87)

(3) Designation of Administrative Responsibility -- LIC 308 (3/87)

(4) Administrative Organization -- LIC 309 (8/86)

(5) Affidavit Regarding Client Cash Resources -- LIC 400 (9/86)

(6) Estimated Operating Budget -- LIC 401 (11/82)

(7) Surety Bond -- LIC 402 (1/87)

(8) Financial Statement -- LIC 403 (3/83)

(9) Financial Information Release and Verification -- LIC 404 (10/86)

(10) Personnel Report -- LIC 500 (10/86)

(11) Personnel Record -- LIC 501 (8/87)

(12) Health Screening Report - Facility Personnel -- LIC 503 (9/86)

(13) Disaster and Mass Casualty Plan -- LIC 610 (10/88)

(b) The applicant/licensee shall cooperate with the Department in providing verification and/or documentation as requested by the Department.

(c) The application and supporting documents shall contain the following:

(1) Name or proposed name and address of facility.

(2) Name, and residence and mailing addresses of applicant.

(A) If the applicant is a partnership, the name, and principal business address of each partner.

(B) If the applicant is corporation or association, the name, title and principal business address of each officer, executive director and member of the governing board.

(C) If the applicant is a corporation, each member of the board of directors, executive director, and any officer shall list the name of all facilities which they have been licensed to operate, employed by or a member of the board of the directors, executive director or an officer.

(D) If the applicant is a corporation which issues stock, the name and address of each person owning more than 10 percent of stock in such corporation.

(E) If the applicant is a corporation, a copy of the articles of incorporation and bylaws.

(F) If the applicant is an association, a copy of the bylaws.

(3) Name and address of owner of facility premises, if applicant is leasing or renting.

(4) The category of facility to be operated.

(5) Capacity requested.

(6) Age range, sex and target group of persons to be served.

(7) Name of administrator.

(8) Information regarding the applicant's 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 facility, residential care facility for the chronically ill, residential care facility for the elderly, or child day care facility, or in any facility licensed pursuant to Chapter 1 (commencing with Section 1200), Chapter 2 (commencing with Section 1250), or Chapter 3 (commencing with Section 1500) of the Health and Safety Code.

(9) Information regarding any revocation or disciplinary action taken or in the process of being taken against a license held or previously held by the entities as specified in Subsection (8) above.

(10) Facility Transfer Agreement with an acute care hospital for the care of residents who require a higher level of care.

(11) Copy of contract with a hazardous waste disposal company for disposal of hazardous materials.

(12) Copy of contract with a Nutritionist.

(13) Copy of contract with a home health agency for case management of the residents and other services as needed.

(14) Copy of contract with a psychologist, psychiatrist, social worker, or other appropriately skilled professional to provide psychosocial support services to the residents, unless the facility will be staffed to provide such services.

(15) Copy of contract with an individual or agency which provides substance abuse counseling, unless the facility will be staffed to provide such services.

(16) Specification of the services to be provided to the targeted population.

(17) Name, address and telephone number of the city or county fire department, the district providing fire protection services, or the State Fire Marshal's Office having jurisdiction in the area where the facility is located.

(18) A plan of operation as specified in Section 87822.

(19) Fingerprint cards as specified in Section 87819(b).

(20) The bonding affidavit specified in Section 87825.

(21) A health screening report on the applicant.

(22) The fee for processing the application as specified in Section 87836.

(23) Such other information as may be required by the Department.

(d) The application shall be signed by the applicant(s).

(1) If the applicant is a partnership, the application shall be signed by each general partner.

(2) If the applicant is a firm, association, corporation, county, city, public agency or other governmental entity, the application shall be signed by the chief executive officer or authorized representative.

(e) The application shall be filed with the licensing office of the Department which serves the geographical area in which the facility is located.

(1) Within 60 days of receipt of the completed application, the Department shall complete a site visit to the facility.

(f) For licensees of existing licensed facilities, the Department shall not require the licensee to complete the entire application process when he/she applies for a new license due to a change in the facility location.

Notes

Cal. Code Regs. Tit. 22, § 87818

1. New section filed 6-7-91 as an emergency; operative 6-7-91 (Register 91, No. 38). A Certificate of Compliance must be transmitted to OAL by 10-7-91 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 12-3-91 as an emergency; operative 12-3-91 (Register 92, No. 9). A Certificate of Compliance must be transmitted to OAL 4-1-92 or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 12-3-91 order including adoption of subsection (e)(1) transmitted to OAL 4-1-92 and filed 5-13-92 (Register 92, No. 23).
4. Amendment of subsections (c)(8) and (c)(22) and amendment of NOTE filed 11-4-96; operative 12-4-96 (Register 96, No. 45).
5. Amendment of subsection (c)(2)(B), new subsection (c)(2)(C), subsection relettering and amendment of NOTE filed 10-4-2000; operative 11-3-2000 (Register 2000, No. 40).
6. Editorial correction of subsections (c)(8), (c)(9) and (c)(18)-(c)(20) (Register 2002, No. 14).

Note: Authority cited: Section 1568.072, Health and Safety Code. Reference: Sections 1568.04, 1568.042, 1568.05 and 1568.072, Health and Safety Code.

1. New section filed 6-7-91 as an emergency; operative 6-7-91 (Register 91, No. 38). A Certificate of Compliance must be transmitted to OAL by 10-7-91 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 12-3-91 as an emergency; operative 12-3-91 (Register 92, No. 9). A Certificate of Compliance must be transmitted to OAL 4-1-92 or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 12-3-91 order including adoption of subsection (e)(1) transmitted to OAL 4-1-92 and filed 5-13-92 (Register 92, No. 23).
4. Amendment of subsections (c)(8) and (c)(22) and amendment of Note filed 11-4-96; operative 12-4-96 (Register 96, No. 45).
5. Amendment of subsection (c)(2)(B), new subsection (c)(2)(C), subsection relettering and amendment of Note filed 10-4-2000; operative 11-3-2000 (Register 2000, No. 40).
6. Editorial correction of subsections (c)(8), (c)(9) and (c)(18)-(c)(20) (Register 2002, No. 14).