Lic 215 Form PDF Details

In the State of California, the Department of Social Services stands as a pivotal institution within the Health and Human Services Agency, particularly through its Community Care Licensing Division. This division employs the LIC 215 form, a comprehensive document designed to gather essential information from all applicants aspiring to secure a license for a facility. Required from individuals, partnerships, or corporate entities, this form meticulously collects data spanning personal to professional background, including but not limited to identifying information, educational background, and references that vouch for both administrative and financial capabilities. Furthermore, it inquires about any prior licensure the applicant may have held, including any disciplinary actions taken against them, their business experience, professional licensure or certificates, membership in professional or technical associations, and a detailed account of their work experience over the last seven years. The form also addresses personal aspects that might impact the applicant's ability to care for residents, underlining the rigorous standards implemented to ensure that those in charge of community care, child care, health facilities, or residential care for the elderly are thoroughly vetted. This procedural diligence accentuates the state's commitment to maintaining high standards in facility management, safeguarding the welfare of its residents through meticulous scrutiny of the backgrounds and capabilities of those seeking licensure.

QuestionAnswer
Form NameLic 215 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescalifornia lic applicant, california applicant information, lic applicant information online, lic applicant

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STATE OF CALIFORNIA

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

HEALTH AND HUMAN SERVICES AGENCY

COMMUNITY CARE LICENSING DIVISION

APPLICANT INFORMATION

This form must be completed by all applicants for a facility license, (i.e., all individuals, each partner in a partnership, or chief executive officer or authorized representative in a corporation.) If more space is required, attach additional sheet. Type or print clearly.

IDENTIFYING INFORMATION

NAME

 

 

SOCIAL SECURITY NUMBER

*

 

 

SEX (M/F)

 

 

 

 

ARE YOU 18 YEARS OR OLDER?

 

 

 

(VOLUNTARY FOR I.D. ONLY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TITLE

 

 

DRIVER’S LICENSE NUMBER

VALID

PLACE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

■ Yes

■ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

(AREA CODE) TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

OTHER NAME(S) USED BY APPLICANT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EDUCATION

 

 

 

 

 

 

 

 

 

Check highest completed grade:1

2

3

4

5

6

7

8

 

9

10

11

12

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND LOCATION OF HIGH SCHOOL

 

 

 

 

 

 

 

 

 

 

 

 

DATE COMPLETED

GED DATE

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND LOCATION OF COLLEGE

 

 

 

 

 

COURSE STUDY

 

YEARS COMPLETED

 

DEGREE

DATE COMPLETED

 

 

 

 

 

 

 

 

 

1

2

3

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

3

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REFERENCES

 

 

 

 

 

 

 

 

 

PERSONAL: (PLEASE GIVE REFERENCES, INCLUDING PRESENT AND PAST EMPLOYERS, WITH KNOWLEDGE OF YOUR ADMINISTRATIVE ABILITY.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

RELATIONSHIP

TELEPHONE

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FINANCIAL: (PLEASE GIVE REFERENCES WITH KNOWLEDGE OF FINANCIAL RESOURCES AND BUSINESS PRACTICES.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

RELATIONSHIP

TELEPHONE

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRIOR LICENSURE STATUS

 

 

 

 

 

 

 

A. HAVE YOU EVER BEEN A LICENSEE OR CO-LICENSEE OF A RESIDENTIAL CARE FACILITY FOR THE ELDERLY,

 

■ YES ■ NO

 

 

 

COMMUNITY CARE, CHILD CARE OR HEALTH FACILITY?

 

 

 

 

 

 

 

 

 

IF YES,, COMPLETE C AND D BELOW.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.HAVE YOU EVER HELD A BENEFICIAL OWNERSHIP OF 10% OR MORE IN A RESIDENTIAL CARE FACILITY FOR THE ELDERLY,

COMMUNITY CARE, CHILD CARE OR HEALTH FACILITY OR BEEN AN ADMINISTRATOR, GENERAL PARTNER, CORPORATE

■ YES ■ NO IF YES, COMPLETE C AND D BELOW:

OFFICER, OR DIRECTOR OF ANY SUCH FACILITY?

 

 

C. NAME AND ADDRESS OF FACILITY

EFFECTIVE DATES OF LICENSURE

FACILITY TYPE

_________________ TO __________________

D.WERE ANY DISCIPLINARY ACTIONS TAKEN?

■ YES

■ NO

IF YES, PLEASE EXPLAIN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BUSINESS EXPERIENCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. HAVE YOU OWNED OR OPERATED ANY BUSINESS?

■ YES

■ NO

 

IF YES, COMPLETE THE FOLLOWING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type

 

Number of

 

Your Title

 

Date

Date

 

Reason for End

 

 

Employees

 

 

Started

Ended

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. DO YOU HAVE A PROFESSIONAL LICENSE OR CERTIFICATE?

■ YES

■ NO

 

IF YES, COMPLETE THE FOLLOWING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type

 

 

 

 

Period Held

 

 

 

Issuing Agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. ARE YOU A MEMBER OF ANY PROFESSIONAL/TECHNICAL ASSOCIATION?

■ YES

 

■ NO

IF YES, COMPLETE THE FOLLOWING:

 

 

 

 

 

 

 

 

 

 

 

 

Association Name

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIC 215 (7/04) (PERSONAL)

WORK EXPERIENCE. BEGIN WITH YOUR MOST RECENT WORK EXPERIENCE. LIST ALL EXPERIENCES AND PERIODS OF UNEMPLOYMENT IN THE LAST SEVEN YEARS. INCLUDE WORK EXPERIENCE FROM MORE THAN SEVEN YEARS, IF NECESSARY.

Dates

Name and Address of Employer

Basic Duties

Termination Reason

FROM

TO

FROM

TO

FROM

TO

FROM

TO

FROM

TO

PERSONAL INFORMATION

A.Do you have any physical, mental, or medical condition that could impair your ability to care for the type of resident/client for whom you have requested licensure?

■ YES

■ NO

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS FORM ARE CORRECT TO THE BEST OF MY KNOWLEDGE.

SIGNATURE

COUNTY WHERE SIGNED

DATE

*Federal law (at Title 5 United States Code Section 552a Note) states that:

Any Federal, State, or local government agency which requests an individual to disclose his social security account number shall inform that individual whether that disclosure is mandatory or voluntary, by what statutory or other authority such number is solicited, and what uses will be made of it.

How to Edit Lic 215 Form Online for Free

It's very easy to fill out the lic 215 applicant information blanks. Our PDF tool can make it almost effortless to complete any specific form. Down below are the basic four steps you need to take:

Step 1: On the web page, choose the orange "Get form now" button.

Step 2: At the moment you're on the document editing page. You can change and add text to the form, highlight specified content, cross or check particular words, include images, put a signature on it, delete unwanted fields, or take them out entirely.

Provide the content demanded by the software to get the form.

ca lic 215 spaces to consider

Provide the demanded data in the HAVE YOU EVER BEEN A LICENSEE OR, YES, NO IF YES COMPLETE C AND D BELOW, HAVE YOU EVER HELD A BENEFICIAL, EFFECTIVE DATES OF LICENSURE, YES, NO IF YES COMPLETE C AND D BELOW, FACILITY TYPE, PRIOR LICENSURE STATUS, D WERE ANY DISCIPLINARY ACTIONS, YES, IF YES PLEASE EXPLAIN, HAVE YOU OWNED OR OPERATED ANY, YES, and IF YES COMPLETE THE FOLLOWING field.

step 2 to entering details in ca lic 215

Outline the key data in the ARE YOU A MEMBER OF ANY, YES, IF YES COMPLETE THE FOLLOWING, Association Name, Address, and LIC PERSONAL box.

step 3 to completing ca lic 215

The Dates, Name and Address of Employer, Basic Duties, Termination Reason, FROM, FROM, FROM, FROM, and FROM section has to be used to put down the rights or responsibilities of each party.

Filling in ca lic 215 part 4

End by looking at all of these areas and writing the pertinent particulars: PERSONAL INFORMATION, Do you have any physical mental or, YES, If yes please explain, I DECLARE UNDER PENALTY OF PERJURY, SIGNATURE, COUNTY WHERE SIGNED, and DATE.

step 5 to finishing ca lic 215

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