Lic 9165-2026

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The document outlines the requirements for board members of group homes in California, emphasizing the necessity for each member to read and sign a statement acknowledging their legal duties and understanding of the regulations governing group home operations. It mandates that licensees provide the publication 'Facts You Need To Know, Group Home Board of Directors' to all board members, who must complete and submit a signed form as a condition of licensure.

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Click ‘Get Form’ to open the lic 9165 in the editor.
Begin by entering the Facility Name and Facility Number in Items 1 and 2. Ensure that the same facility number is used for all board members to maintain proper association.
In Item 3, clearly print your name. This is essential for identification purposes.
Provide your Daytime Telephone Number in Item 4, followed by your complete Mailing Address in Item 5 (Items 6, 7, and 8 for City, State, and Zip respectively).
Sign the form in Item 9. Remember that all signatures must be original.
Finally, enter the Date in Item 10 to complete the form. Review all entries for accuracy before saving.

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What is lic 200?

Application for a Child Care Center License LIC 200A. Application For A Community Care Facility or Residential Care Facility For The Elderly License LIC 200.

What is lic 9224?

Acknowledgement of Receipt of Licensing Reports (LIC 9224), if applicable. This information is requested by the Department of Social Services in compliance with Title 22, Division 12 of the California Code of. Regulations and Section 1596.70 et. Seq. of Health and Safety Code.

What is the lic 500 form?

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. PERSONNEL REPORT. INSTRUCTIONS: This form is intended for keeping a current roster of all the facility personnel, other adults and licensees residing in the facility, including backup persons, volunteers and licensee if administrator/director.

What is LIC 602?

Form 602 is issued by the California Department of Social Services. The form was established as a way to help senior communities better understand the needs of potential residents in terms of medical assistance, nutritional needs, mental and physical capabilities and other care requirements.

What lic form number is the reference request?

References are to be completed on the Reference Request-Exemption form (LIC 301E).

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