Lic 9054 Form PDF Details

In the intricate dance of ensuring the safety and compliance of community care facilities, the Lic 9054 form plays a crucial role, acting as a bridge between care providers and local fire inspection authorities in California. Managed by the Department of Social Services, Community Care Licensing Division, this form is a key step in the application process for those seeking to operate a facility that provides community care. By accurately identifying and providing contact information for the local fire inspection authority responsible for their facility, applicants facilitate the timely inspection and certification process that is essential not only for compliance but also for the peace of mind of those who entrust their loved ones to these facilities. Ensuring that fire safety measures are thoroughly evaluated and approved underscores the commitment of care providers to the safety and wellbeing of their charges. The Lic 9054 form, therefore, serves not merely as a bureaucratic necessity but as a testament to the overarching standards of care and safety upheld within California's community care facilities.

QuestionAnswer
Form NameLic 9054 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesobtaining, lic9054, LIC, family checklist for lic

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STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY

LOCAL FIRE INSPECTION AUTHORITY INFORMATION

REQUIRED BY THE DEPARTMENT OF

SOCIAL SERVICES, COMMUNITY CARE LICENSING

DIVISION

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COMMUNITY CARE LICENSING

DATE:

APPLICANT NAME:

FACILITY NAME:

FACILITY ADDRESS:

As part of the application process, the licensing agency is responsible for obtaining a fire safety inspection from the local fire inspection authority having jurisdiction in the area where your facility is located.

To help us expedite this process, we are requiring that you identify the local fire inspection authority that is responsible to inspect your facility and issue a fire clearance.

LOCAL FIRE INSPECTION AUTHORITY:

ADDRESS:

CITY AND ZIP CODE:

PLEASE RETURN THIS FORM WITH YOUR COMPLETED APPLICATION

LIC 9054 (3/99)

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