Transcription of STATE OF CALIFORNIA - HEALTH AND HUMAN …
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STATE OF CALIFORNIA - HEALTH AND HUMAN …
STATE OF CALIFORNIA - HEALTH AND HUMAN services agency CALIFORNIA department OF social services . COMMUNITY CARE LICENSING DIVISION. APPLICATION FOR ADMINISTRATOR CERTIFICATION For Office Use Only: ADMINISTRATOR CERTIFICATION PROGRAM PRINTS TO DOJ: _____. DOJ CLEARED: _____. Instructions: See page 2 for complete instructions. FBI CLEARED: _____. (1) Type of Application: (Check one box only. If renewing, provide certificate number CACI: _____. and expiration date.). FACILITY #: _____. New Renewal Certificate #_____ Expires: _____ #: _____. (2) Type of Program: (Check one box only; if applying for more than one certificate, LIS #: _____. submit separate application for each.). ARF (Adult Residential Facility) GH (Group Home) RCFE (Residential Care Facility for the Elderly).
state of california - health and human services agency california department of social services community care licensing division lic 9214 (6/16) page 2 of 2
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