Transcription of COMMUNITY CARE LICENSING DIVISION …
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COMMUNITY CARE LICENSING DIVISION …
STATE OF california - HEALTH AND HUMAN services AGENCYCALIFORNIA department OF social SERVICESCOMMUNITY care LICENSING DIVISIONADMINISTRATIVE organization (This side is for corporations and limited liability companies only. See reverse for public agencies,partnerships, and other associations.)INSTRUCTIONS:This form must be updated and submitted to the LICENSING Agency each time there is a changein partners, officers or changes in the corporation or limited liability company as provided in theCallifornia Code of Regulations Title 22, Section 80034(a)(2), or 87235(a)(5), or 101185(a)(2).DATEFACILITY NAMEFACILITY ADDRESSFACILITY NUMBERI. CORPORATION/LIMITED LIABILITY COMPANY (LLC) (as filed with Secretary of State) Executive DateContact Person:Title:Telephone No.:6. Principal office of business:AddressCityZip CodeCountyTelephone Out of state or foreign applicants complete the following:a.
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION. ADMINISTRATIVE ORGANIZATION (This side is for corporations and limited liability companies only. See reverse for public agencies, partnerships, and other associations.) INSTRUCTIONS: This form must be updated and submitted to the Licensing Agency each …
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