Lic 9165 Form PDF Details

Managing a group home in the State of California demands adherence to various regulations, among which the Lic 9165 form plays a crucial role. This form serves as a declaration by members, and prospective members, of a group home’s board of directors, affirming their understanding of the legal duties and obligations tied to their roles. The essence of this document is to ensure that those at the helm of group home management are not only aware but also compliant with the laws and regulations as enforced by the Department of Social Services. Completing and signing the Lic 9165 form is not just a procedural step; it is a mandatory requirement for licensure. It necessitates that each board member receives, reads, and acknowledges the contents of the Community Care Licensing’s publication "Facts You Need To Know, Group Home Board of Directors." The form includes critical information such as the facility name and number, personal and contact information of the board member, and, most importantly, their signature as a testament to their commitment to comply with the stated regulations. As regulations evolve, it is highlighted that the accompanying booklet may not always capture the most up-to-date laws, urging a continuous effort from the board members to stay informed. This initiates an ongoing responsibility for those governing group homes to ensure their operations align with current standards, safeguarding both the facility's licensure status and the well-being of its residents.

QuestionAnswer
Form NameLic 9165 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesLicensees, licensee, LIC, ensures

Form Preview Example

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

BOARD OF DIRECTOR STATEMENT

IMPORTANT– Before completing, see reverse for instructions.

Licensees are required to provide a copy of the Community Care Licensing’s publication, Facts You Need To Know, Group Home Board of Directors, to each member of their board of directors. The members of the board of directors are required to read and sign the statement below. This form must be completed by all board members. The signing of this form by all members, and prospective members, of the board of directors is a condition of licensure.

I have read and understand my legal duties and obligations as a member of the board of directors and I also understand that the group home’s operation is governed by laws and regulations that are enforced by the Department of Social Services, as set forth in the publication, Facts You Need To Know, Group Home Board of Directors.

I declare that I have received a copy and I have read and understand the information contained in the publication, Facts You Need To Know, Group Home Board of Directors.

1.

Facility Name

 

2.

Facility Number

 

 

 

 

 

 

3.

Your Name (Print Clearly)

 

4.

Daytime Telephone No.

 

 

 

 

 

 

5.

Your Mailing Address

6. City

7.

State

8. Zip

 

 

 

 

 

 

9.

Signature

 

10.

Date

 

 

 

 

 

 

 

Note: The publication, Facts You Need To Know, Group Home Board of Directors booklet is only as current as the initial publishing date or any later revision date. Therefore, the booklet may not include information on the most current law and regulation changes that you may need to know. Boards of directors should ensure that they are informed of law and regulation changes.

LIC 9165 (2/99)

BOARD OF DIRECTOR STATEMENT

INSTRUCTIONS

General Information

As stated on the front side, each member of the board of directors must sign this form. Also, prospective board members must read the Group Home Board of Directors booklet and sign this form before joining the board. This form may be copied and given to each of your members for their signature. The signed forms must be kept at the group home’s administrative office. The signed forms must be available to licensing staff for inspection upon request.

Instructions

Please type or clearly print the information being requested by each item number.

Items 1. and 2. Enter the facility name and number. When a corporate licensee has more than one facility, it is important that the same facility number is used for all board members. This ensures that each and all board members are associated and identified with the correct corporate licensee. It is acceptable to enter this on behalf of the board member.

Items 3.-10.The board member enters his or her name, daytime telephone number, complete mailing address, signature and date. All signatures must be original.

I have read and understand my legal duties and obligations as a member of the board of directors and I also understand that the group home’s operation is governed by laws and regulations that are enforced by the Department of Social Services, as set forth in the publication, Facts You Need To Know, Group Home Board of Directors.

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