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The Lic 215 form is an essential document used in the application process for a facility license in California. This form must be filled out by all individuals involved in the application, including partners and authorized representatives of corporations. It gathers various pieces of information that help assess the qualifications and background of the applicant. Key sections include personal identifying information, education history, and work experience, providing a comprehensive view of the individual seeking licensure. Applicants are also prompted to list references, both personal and financial, which showcase their administrative and business capabilities. Furthermore, the form inquires about any prior licensing status and disciplinary actions taken against the applicant, ensuring that all relevant aspects of a candidate's history are considered. For those with business experience, there are sections to detail ownership history and professional affiliations, painting a complete picture of the applicant's qualifications. Lastly, the form addresses personal health information that might affect the individual’s capability to provide care for residents. With its structured layout, the Lic 215 form simplifies the process of applying for necessary licenses while ensuring essential information is disclosed.

Lic 215 Example

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.

Form Characteristics

Fact Name Description
Purpose The LIC 215 form is required for all individuals applying for a facility license in California.
Applicant Information All applicants must provide personal details, including Social Security number, address, and driver’s license number.
Age Requirement Applicants must indicate if they are 18 years or older; however, responding is voluntary.
Educational Background Applicants are asked to check their highest completed grade and provide details on high school and college education.
Prior Licensure History The form queries prior experience as a licensee or co-licensee of a care facility and requires explanations if disciplinary actions were taken.
Business Experience Applicants must disclose any past business ownership or operation and professional licenses held, if applicable.
References Two personal and two financial references with relevant knowledge must be provided, including contact information.
Disability Disclosure Applicants are required to disclose any physical or mental conditions that might affect their ability to provide care.
Governing Law This form is governed by California’s Health and Safety Code, specifically relating to community care licensing.
Signature Requirement An applicant must sign the form, declaring the accuracy of their provided information under penalty of perjury.

Guidelines on Utilizing Lic 215

Completing the Lic 215 form is an important step for individuals seeking a facility license in California. Attention to detail is crucial to ensure the information provided is both accurate and comprehensive.

  1. Begin by entering your basic identifying information. This includes your name, social security number, and sex. Mark whether you are 18 years or older and fill out your title and driver’s license number.
  2. Provide your place of birth and the address, including your telephone number.
  3. List any other names you have used.
  4. Check the box corresponding to the highest grade you completed in the education section.
  5. Write the name and location of your high school and the date completed; if applicable, provide GED completion date.
  6. If you attended college, include the name and location of the institution, fields of study, years completed, and the degree and date received.
  7. In the references section, list personal references including name, address, relationship, and telephone number. You should provide at least two present or past employers.
  8. Complete the financial references section in a similar manner.
  9. Answer the questions in the prior licensure status section honestly. If you answer “yes,” complete the subsequent fields regarding your prior licensing details.
  10. In the business experience section, indicate if you have owned or operated any business, providing necessary details.
  11. Answer whether you have a professional license or certificate, and if so, complete the respective details.
  12. If applicable, note any professional or technical associations you belong to, including the association name and address.
  13. In the work experience section, list all relevant experiences chronologically. Include duties, termination reasons, and any gaps in employment as necessary.
  14. Address any personal medical conditions that could affect your ability to care for clients, if applicable.
  15. Finally, sign and provide the date in the declaration section, affirming the truthfulness of the information provided.

What You Should Know About This Form

1. What is the purpose of the Lic 215 form?

The Lic 215 form is used by individuals seeking a facility license in California. It collects essential information about the applicant, including their personal details, educational background, work history, and any professional licenses they may hold. This information helps the California Department of Social Services assess the qualifications of the applicants.

2. Who needs to fill out the Lic 215 form?

All applicants for a facility license must complete the Lic 215 form. This includes individuals, partners in a partnership, and authorized representatives of a corporation. Each person involved in the licensing process must provide their information to ensure compliance with state regulations.

3. Is it necessary to provide my Social Security number?

Yes, if applicable, your Social Security number is required on the Lic 215 form. Federal law mandates that agencies must inform individuals whether providing this number is mandatory or voluntary. In this case, it is necessary for identification and verification purposes during the licensing process.

4. Can I submit additional information if necessary?

Absolutely. If you require more space than what is provided on the form, you can attach additional sheets. Just be sure to indicate the relevant section of the Lic 215 form that corresponds with the extra information for clarity.

5. What information is required regarding my education?

The form asks for your highest completed level of education, the name and location of your high school or college, and any degrees earned. This information is vital as it demonstrates your educational qualifications relevant to the type of facility you are seeking to operate.

6. Are there any questions related to prior licensing status?

Yes, the Lic 215 form includes questions about your history with previous licenses for various types of facilities. You will need to disclose if you have held any licenses or beneficial ownership roles and whether disciplinary actions were ever taken against you. This information aids in the overall assessment of your suitability for licensure.

7. What details should I include about my work experience?

You should list all relevant work experiences for the past seven years, along with any periods of unemployment. This section needs to include the name and address of your employer, your basic duties, and reasons for termination. If your work experience extends beyond seven years, it can be included as well, especially if it is pertinent to your application.

8. Is it important to provide references?

Yes, you must provide both personal and financial references. These references help verify your administrative capabilities and financial practices. For personal references, include past employers. Financial references should be individuals familiar with your business resources.

9. What if I have a medical condition? Do I have to disclose it?

The Lic 215 form does ask whether you have any medical, physical, or mental conditions that could impair your ability to provide care. Honesty is crucial, as this information is necessary for evaluating your capability to care for the residents or clients you intend to serve.

10. How is the information on the Lic 215 form protected?

While the form collects sensitive information, it is subject to privacy regulations. The California Department of Social Services adheres to specific rules regarding the handling of personal information, ensuring it is used solely for the purpose of the licensing process. If you have concerns about privacy, inquire about the agency's policies regarding data protection.

Common mistakes

Completing the Lic 215 form can be a straightforward process, but many applicants encounter common mistakes that can delay their application. One frequent error is failing to provide accurate identifying information. It is crucial to ensure that the name, social security number, and driver’s license number match the official documents. Any discrepancies may lead to confusion and could result in the rejection of the application. Double-checking this section can save a lot of time.

Another common mistake is neglecting to answer all questions fully. For instance, applicants often skip the sections that inquire about previous licensure status or business experience. Responding to all parts of the questionnaire is essential. If certain questions are not applicable, it is better to indicate that rather than leave them blank. This practice allows for a clearer understanding of the applicant’s background.

Inadequate references can also pose a problem. Many applicants do not provide enough personal or financial references, which are necessary for verifying qualifications. It is advisable to list more than the minimum number of references needed and to ensure that those listed have detailed knowledge of the applicant’s skills and experience. This step reinforces the applicant's credibility and supports the overall application.

Lastly, many individuals overlook the declaration of accuracy at the end of the form. They may forget to sign the document or mistakenly believe the signature is unnecessary. This final step is crucial; without a signature, the application cannot be processed. Taking the time to review the entire form before submission ensures that all details are complete and accurate, thus facilitating a smoother licensing process.

Documents used along the form

When applying for a facility license, the Lic 215 form is just one piece of the puzzle. To ensure a complete application, several other documents may be required. Each of these forms plays a critical role in the licensing process.

  • Application for Licensing (Lic 200): This primary document initiates the licensing process. It gathers essential information about the facility itself, including its legal structure, proposed services, and physical location.
  • Criminal Record Statement (Lic 508): To protect vulnerable populations, this form confirms that all applicants have undergone a thorough background check. It ensures that individuals with any disqualifying criminal history are identified before they can care for residents.
  • Disclosure of Ownership (Lic 610): This document outlines all individuals and entities with ownership interests in the facility. Transparency about ownership helps clarify relationships and responsibilities among stakeholders.
  • Facility Sketch (Lic 401): A visual representation of the facility's layout, this document helps reviewers assess compliance with safety regulations and ensures adequate space for residents. The sketch includes critical areas like living spaces, exits, and bathrooms.

Each of these documents, along with the Lic 215 form, provides a comprehensive view of the applicant and the facility. Submitting complete and accurate information is crucial for a smooth licensing process. Review each requirement carefully to avoid delays.

Similar forms

The Lic 215 form is an important document for individuals applying for a facility license in California. Similar forms serve comparable functions in various contexts. Below are five documents that share similarities with the Lic 215 form, each important in their own right.

  • Form I-9: This document verifies the identity and employment authorization of individuals hired for employment in the U.S. Both forms require personal information, including social security numbers and addresses, to ensure compliance with legal standards.
  • IRS Form W-4: Used by employees to indicate tax situation, this form also collects identifying information. Like the Lic 215, it necessitates accurate information from applicants to fulfill regulatory requirements.
  • California Driver's License Application: This form is used to apply for a driver's license and requires personal details, including identifying information and proof of residency. Both documents emphasize the need for truthful and comprehensive responses.
  • Social Security Administration Application: When applying for Social Security benefits, individuals must fill out a form that collects personal data, similar to the Lic 215. Both require clear identification to prevent fraud and ensure the protection of sensitive information.
  • Business License Application: In many jurisdictions, individuals seeking to start a business must complete an application that gathers personal and business-related information. The emphasis on comprehensive background and personal history in both forms supports regulatory oversight and establishes accountability.

Dos and Don'ts

When filling out the Lic 215 form, it's essential to approach the task with care and attention to detail. Here are seven key dos and don'ts to keep in mind:

  • Do read the instructions thoroughly before you start. Understanding the requirements will save you time and ensure accuracy.
  • Don't rush through the form. Taking your time helps prevent mistakes that could delay the application process.
  • Do provide complete and accurate information. Every section is important, and incomplete or inaccurate data can lead to complications.
  • Don't leave any relevant spaces blank. If a question doesn't apply to you, it's often best to write "N/A" instead of leaving it empty.
  • Do ensure your handwriting is clear and legible if you're filling out the form by hand. This helps the reviewers read your information without confusion.
  • Don't forget to double-check your answers before submitting. A quick review can catch potential errors or omissions.
  • Do sign and date the form where indicated. Without your signature, the application may not be considered valid.

Following these steps can facilitate a smoother application process, helping you to avoid common pitfalls. It's always better to be thorough and accurate.

Misconceptions

Misconception 1: The Lic 215 form is only for new applicants.

This is not true. The Lic 215 form is required for anyone applying for a facility license, including those who have previously held a license.

Misconception 2: Providing my Social Security number is mandatory.

While the form requests a Social Security number, federal law states that the disclosure is actually voluntary. You're informed that you can choose whether or not to provide it.

Misconception 3: I need to have a college degree to fill out the form.

The Lic 215 form asks for your highest completed grade, but having a college degree is not a requirement. Applicants from various educational backgrounds can fill out the form.

Misconception 4: The form requires extensive financial documentation.

This is misleading. The form simply asks for references knowledgeable about your financial resources and business practices. No extensive financial documents are needed at this stage.

Misconception 5: A criminal record automatically disqualifies me from licensing.

This depends on the nature of the record and the specific rules regarding the type of facility. Each case is evaluated individually, so a past criminal record may not lead to immediate disqualification.

Key takeaways

Filling out the Lic 215 form requires careful attention to detail. Here are seven key takeaways to keep in mind.

  • Complete All Sections: Ensure each part of the form is filled out completely. Missing or incomplete information can delay the licensing process.
  • Provide Clear Identifying Information: Include your name, social security number, and other personal details clearly. Use block letters if necessary.
  • Answer Truthfully: It is crucial to answer "Yes" or "No" questions accurately. Information about prior licensure or disciplinary actions may impact your application.
  • Include References: Provide personal and financial references who can vouch for your administrative abilities and business practices. Ensure they are knowledgeable about your background.
  • Detail Work and Education History: List all relevant work experiences, education, and any professional licenses or certifications. This information is necessary for verifying your qualifications.
  • Evaluate Medical Conditions: Be open about any medical conditions that might affect your ability to care for clients. Transparency can facilitate better care practices.
  • Sign and Date: Remember to sign and date the form. This declaration confirms that the information provided is accurate and complete.

Following these guidelines can help streamline the licensing process and strengthen your application. Good luck!