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NOTIFICATION OF INCOMPLETE APPLICATION

SECTION A LICENSING FORMS for Facility License (LIC 200 or LIC 200A) Information (LIC 215)For: _____ of Administrative Responsibility (LIC 308) Organization (LIC 309) Regarding Client/Resident Cash Resources(LIC 400) Monthly Operating Budget (LIC 401) Bond (LIC 402) Statement (LIC 403) Information Release and Verification (LIC 404) A10. Budget Information (LIC 420) A11. Personnel Report (LIC 500) A12. Personnel Record (LIC 501) A13. Health Screening Report Facility Personnel (LIC 503)For: _____ A14. Emergency Disaster Plan (LIC 610 or LIC 610A) A15. Facility Sketch (LIC 999) A16. Local Fire Inspection Authority Information (LIC 9054)STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESNOTIFICATION OF INCOMPLETE APPLICATIONDATE:FACILITY NAME:FACILITY FILE NUMBER:NAME OF PERSONNAME OF PERSON(S) This INCOMPLETE APPLICATION package is being returned to you.

SECTION A — LICENSING FORMS A1. Application for Facility License (LIC 200 or LIC 200A) A2. Applicant Information (LIC 215) For: _____ A3. Designation of Administrative Responsibility (LIC 308)

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