Adh 0014 form-2025

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The document is a request form for program flexibility under the Adult Day Health Care Program in California, allowing licensees to propose alternatives to specific regulatory requirements. It includes sections for the licensee's information, reasons for the request, and assurances that the proposed changes will not negatively impact service quality or participant care.

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Click ‘Get Form’ to open the ADH 0014 form in the editor.
Begin by entering the Licensee Name and Center Name in the designated fields. Ensure accuracy as this information is crucial for identification.
Input the Phone Number, including area code, and complete the Center Address fields to provide contact details.
Specify the Requested Effective Date and Estimated Duration of the program flexibility request. This helps in planning and compliance.
In the section for Program flexibility requested, indicate the relevant Title 22, California Code of Regulations, Section(s) that apply.
Provide a detailed Reason for requesting program flexibility and a Description of proposed alternative to meet regulatory requirements.
Explain how you have determined that your proposed alternative will not adversely affect participants, ensuring their safety and well-being.
Finally, print the Administrator's Name and obtain their signature to validate the request before submission.

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