ADH 0006 (PDF) - California Department of Public Health - State of ... - cdph ca-2026

1. Click ‘Get Form’ to open it in the editor.
2. In Box #1, enter the Licensee Name for your organization.
3. In Box #2, input the Center’s Hours of Service as defined in Health and Safety Code Section 1570.7(h).
4. For Box #3, provide the Center’s licensed capacity as indicated on the ADHC license.
5. In Box #4, calculate and enter the average daily attendance (ADA) for the previous quarter.
6. Enter the Center’s name in Box #5.
7. Circle 'Yes' or 'No' in Box #6 to indicate if Adult Day Program services are provided.
8. Box #7 requires the signature and date from the Center's Administrator or Program Director.
9. List each staff member's name in Box #8, noting any approved program flexibility with '(PF)'.
10. In Box #9, specify each staff member's scheduled hours per month.
11. Enter each staff member's date of hire in Box #10.
12. Provide license, registration, or certification numbers along with expiration dates in Box #11 if applicable.
13. Finally, list meal and transportation providers' names in Box #12.

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