The signing of this form by all members, and prospective members, of the board of directors or governing body is a condition of licensure.
Prospective members: must read the Group Home and Short-Term Residential Therapeutic Programs Board of Directors booklet and sign the above LIC 9165 form before joining.
Signed forms: the signed forms must be kept at the Group Home or STRTP administrative office.
Inspection: all signed forms must be available to Department staff for inspection upon request.
Signatures: all signatures must be original.
| Question | Answer |
|---|---|
| Form Name | LIC 9165 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 13 |
| Avg. time to fill out | 3 min |
| Edition | Rev 4/22 |
| Issuing agency | California Department of Social Services |
| Signed forms | Must be kept at the Group Home or STRTP administrative office |
| Matches the agency's file | Yes, checked October 7, 2026 |
| Other names | LIC 9165, LIC9165, Form LIC 9165, Board of Director or Governing Body Statement |
| Official source | LIC 9165 (Rev 4/22), California Department of Social Services |
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