Application for Licensing of an Adult Day Health Center

The following forms and documents are required for licensure.

In addition to the forms below, you are required to submit additional documents for a change of ownership.  These documents must be submitted with your completed application.  The required information and instructions are listed on the checklist contained in the “Adult Day Health Center Application Request Letter and Instructional Checklist” (pdf)letter.

Adult Day Health Center

Required Forms to be Licensed:

• Licensure & Certification Aplication: HS 200 (PDF)
• Application Individual Information: HS 215A (PDF)
• Administrative Organization: HS 309 (PDF)
• Transmittal Application For Criminal Background Investigation: CDPH 322 (PDF)
• Transfer Agreement: HS 602 (PDF)
• Bed or Service Request: CDPH 609 (PDF)
• Civil Rights Compliance Review (Title VI, Section 504, ADA): DHCS 1051 (PDF)
• Staffing/Services Arrangement: ADH 0006 (PDF)
• Proposal To Share Space: ADH 0007 (PDF)
• Program Flexibility Request: ADH 0014 (PDF)
• Request for Live Scan Service: BCIA 8016 (PDF) ...Sample Form
  (For correct application routing, please fill in BCIA 8016 ORI field with A1226)
• Administrator and Program Director Information: CDA 278 (PDF)
• Local Fire Inspection Authority Information: CDA 282 (PDF)
• Balance Sheet: IMS 33 (PDF)
• Cash Flow Forecast: IMS 35 (PDF)
• Operating Budget: IMS 37 (PDF)