Form ca 16 2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. Fill in your Mailing Address, E-Mail Address, Contact Person, and Telephone Number. Ensure all information is current and accurate.
4. For Line 1, enter the number of facilities currently licensed and pending licensure under your corporate name for this group home program.
5. Continue with Line 2 by indicating the number of facilities owned by your corporation that have clear title or a mortgage/deed of trust.
6. 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.
7. Complete Line 4 by answering whether there are any other shelter costs resulting from self-dealing transactions. Provide details if applicable.
8. 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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