A Facility License - Section A & B

This Section for A Facility License (Part A) are for filing an application for the following:

        - Adult Residential Facility   - Group Homes   - Small Family Homes   

- Residential Care Facility for Elderly (RCFE)   

  -Adult Day Programs 

 Licensing Form

 Description

A1. Application  (LIC 200)

Identifies applicant(s) and facility for licensure.

A2. Applicant Information (LIC 215)

Submitted by applicant(s), e.g., individual(s), chief executive officer(s) of a corporation, general partners of a partnership, or controlling partner(s) in a limited liability company.

A3. Designation of Facility Responsibility (LIC 308)

Identifies the person authorized by the licensee to accept responsibility for the facility in the licensee's absence.

A4. Administrative Organization (LIC 309)

Identifies the organization of a corporation, the board of officers, and anyone having a beneficial ownership of 10 percent or more in the corporation.  Also required for a partnership, limited liability company, and public agency application.

A5. Affidavit Regarding Client Cash Resources (LIC 400)

A6. Surety Bond (LIC 402)

A7. Monthly Operating Statement (LIC 401)

Establishes estimated gross profit based on income from children's care, less operation costs.

A8a. Supplemental Financial Information (LIC 401a)

A8b. Balance Sheet (LIC 403)

Compilation of total assets and liabilities to establish equity of applicant(s). A credit check may be obtained to verify financial ability to operate the facility.

A8c. Balance Sheet Supplemental Schedule (LIC 403a)

Compilation of total assets and liabilities to establish equity of applicant(s). A credit check may be obtained to verify financial ability to operate the facility.

A9. Financial Information Release and Verification (LIC 404)

Provides financial information that is verified by a bank or other financial institution. 

A10. Personnel Report (LIC 500)

Show all planned employee positions. Includes days and hours staff will be on duty.

 

A11. Personnel Record (LIC 501)

To be completed by site director if other than applicant

A12. Health Screening Report - Facility Personnel (LIC 503)

Verifies health of applicant(s) and site director to effectively perform duties as required.

A13. Criminal Record Statement (LIC 508)

Identifies applicant(s) and facility for licensure.

A14. Emergency Disaster Plan (LIC 610E)

Plan developed by applicant to enable facility to handle any emergency that may arise and to protect the safety and well-being of each child.

A15. Facility Sketch (LIC 999)

Required for all indoor and outdoor space.  The front of the form is for a floor plan; the back is for a yard sketch.

A16. Local Fire Inspection Authority Information (LIC 9054)

To be completed by any applicant who intends to serve non-ambulatory children or children with disabilities or special health care needs.

Part B

The Licensing application for Part B is a biography of what type of program you want to serve and the experiences you can provide for the program you choose. 

The Vendors Point of View section of Part B created a tool that provides you an outline on what Community Care Licensing Application is looking for.

VENDORS . Point of View

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