Form LIC 9165 at a glance
What it is: LIC 9165, the Board of Director or Governing Body Statement of the California Department of Social Services, is signed by each member of the board of directors or governing body.
Who signs: Each member of the board of directors or governing body must sign this form.
This form must be completed by all members of the board of directors or governing body.
Prospective members of the board of directors or governing body must read the Group Home and Short-Term Residential Therapeutic Programs Board of Directors booklet and sign the LIC 9165 form before joining the board or governing body.
A filled-in Form LIC 9165 example: a board member signs the statement
How to fill out Form LIC 9165, box by box
Facility Name and Facility Number
Enter the Facility Name in Box 1 and the Facility Number in Box 2.
Your Name, Daytime Telephone No. and Mailing Address
Enter Your Name (Print Clearly) in Box 3 and the Daytime Telephone No. in Box 4.
Enter Your Mailing Address in Box 5, then the City in Box 6, the State in Box 7 and the Zip in Box 8.
Please type or clearly print the information being requested by each item number.
Signature, Date You Joined Board and Date of Signature
"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 and Short-Term Residential Therapeutic Program Board Of Directors."
Sign in Box 9, enter the Date You Joined Board in Box 10 and the Date of Signature in Box 11.
All signatures must be original.
More rules for Form LIC 9165
Items 3 to 10: The member of the board of directors or governing body enters their name, daytime telephone number, complete mailing address, signature and date.
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 or STRTP administrative office.
All signed forms must be available to Department staff for inspection upon request.
"I have read and understand my legal duties and obligations as a member of the board of directors or governing body and I also understand that the group home and short-term residential therapeutic program's operation is governed by laws, regulations, and interim licensing standards that are enforced by the Department of Social Services, as set forth in the publication, Facts You Need to Know, Group Home and Short-Term Residential Therapeutic Program Board of Directors."
The publication, Facts You Need to Know, Group Home and Short-Term Residential Therapeutic Program 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, regulation, and interim licensing standard changes that you may need to know. Members of the Board of Directors or governing body should ensure that they are informed of law, regulation, and interim licensing standard changes.
Common questions about Form LIC 9165
Who signs it?
Each member of the board of directors or governing body must sign this form.
Sources
[1] Form LIC 9165 (4/22), Board of Director or Governing Body Statement, California Department of Social Services (the Official source link on this page).