Licensing and Certification

Application for Health Facility Change of Location (PDF)

Request for Adult Day Health Care (ADHC) Center Moratorium Exemption (PDF)

A listing of forms, application letters, and checklists used by L&C (PDF)

Staffing/Services Arrangement (PDF)

Proposal to Share Space (PDF)

Request for Designation as a Rural Alternative Adult Day Health Care (ADHC) Center (PDF)

Adult Day Health Care Program Flexibility Request (PDF)

Administrator and Program Director Information (PDF)

Local Fire Inspection authority Information (PDF)

Civil Rights Compliance Review (Title VI, Section 504, ADA) (PDF)

Assurance of Compliance With the Department of Health, Education, and Welfare Regulation Under Title VI of the Civil Rights Act of 1964 (PDF)

Licensee Balance Sheet (PDF)

Cash Flow Forecast (PDF)

Medi-Cal Participation Agreement (PDF)

Operating Budget (PDF)

Disclaimer of Conflict of Interest (PDF)