APPLICATION FOR A COMMUNITY CARE ... - CDSS …

THE INFORMATION BELOW FOR ANY RESIDENTIAL care OR HEALTH care FACILITY PREVIOUSLY OR CURRENTLY OPERATED. REFER TO NAME AND NUMBERLICENSING AGENCY NAMEA. _____B. _____ ADULT RESIDENTIAL FACILITIES SOCIAL REHABILITATION FACILITIES RESIDENTIAL FACILITIES--ELDERLY FOSTER FAMILY AGENCIES ADOPTION AGENCIES RESIDENTIAL FACILITIES--CHRONICALLY ILL ADULT DAY PROGRAMS GROUP HOMES SMALL FAMILY HOMES TRANSITIONAL HOUSING PLACEMENT PROGRAMS CRISIS NURSERIES OTHER( SPECIFY)_____FOR DEPARTMENT USE ONLYDISTRICT:COUNTY:FACILITY NUMBER:DATE:ACTION TYPE:REVIEWED BY:FACILITY OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICESAPPLICATION FOR A COMMUNITY care FACILITY OR RESIDENTIAL care FACILITYFOR THE ELDERLY LICENSE(See Instructions on next page)REPLY (S) NAME(S) (PLEASE PRINT) MAILING OF AGENCY OR OR PERSON IN CHARGE OF AND HOURS

INSTRUCTIONS FOR APPLICATION FOR FACILITY LICENSE Type or print clearly. Prepare application in duplicate. Return original and maintain a copy for your records.

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