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Form ca 16 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your Licensee/Corporate Name and Program Number at the top of the form. If you are a new provider, leave the Program Number blank.
- Fill in your Mailing Address, E-Mail Address, Contact Person, and Telephone Number. Ensure all information is current and accurate.
- For Line 1, enter the number of facilities currently licensed and pending licensure under your corporate name for this group home program.
- Continue with Line 2 by indicating the number of facilities owned by your corporation that have clear title or a mortgage/deed of trust.
- On Line 3, specify the number of facilities with a rental or lease agreement. Break this down into Lines 3a and 3b for self-dealing transactions as instructed.
- Complete Line 4 by answering whether there are any other shelter costs resulting from self-dealing transactions. Provide details if applicable.
- Finally, ensure to sign the certification section at the end of the form before submitting it via mail to the California Department of Social Services.
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