CA HHSA DSS LIC 9142A 2006 free printable template
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STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES ROSTER OF PARTICIPANTS FOR VENDOR USE ONLY 35/40 HOUR INITIAL OR CEU COURSES ADMINISTRATOR CERTIFICATION
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How to fill out CA HHSA DSS LIC 9142A
01
Obtain the CA HHSA DSS LIC 9142A form from the appropriate agency or website.
02
Fill out the personal information section, including your name, address, and contact details.
03
Provide information about the facility, including its address and type of services offered.
04
Complete the required sections regarding licensing history, including any previous licenses held.
05
Answer questions related to staffing, including qualifications and training of staff members.
06
Indicate any health and safety measures implemented at the facility.
07
Review the entire form for accuracy and completeness.
08
Sign and date the form as required.
09
Submit the completed form to the appropriate department or agency for processing.
Who needs CA HHSA DSS LIC 9142A?
01
Individuals or organizations seeking to operate a community care facility in California.
02
Existing facility operators who need to renew or update their license.
03
Those responsible for ensuring compliance with state licensing requirements.
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What is CA HHSA DSS LIC 9142A?
CA HHSA DSS LIC 9142A is a specific form used by the California Department of Social Services for licensing purposes, particularly for facilities that provide care services.
Who is required to file CA HHSA DSS LIC 9142A?
Facilities that are seeking to be licensed or are renewing their license to operate facilities providing care services in California are required to file CA HHSA DSS LIC 9142A.
How to fill out CA HHSA DSS LIC 9142A?
To fill out CA HHSA DSS LIC 9142A, you need to provide accurate information about the facility, including details about ownership, services provided, and compliance with health and safety regulations as set forth by the California Department of Social Services.
What is the purpose of CA HHSA DSS LIC 9142A?
The purpose of CA HHSA DSS LIC 9142A is to gather necessary information to assess and evaluate facilities for compliance with state licensing requirements, ensuring that they meet the standards for providing care services.
What information must be reported on CA HHSA DSS LIC 9142A?
The information that must be reported on CA HHSA DSS LIC 9142A includes the facility’s name, address, ownership details, number of clients, services provided, staff qualifications, and any prior violations or complaints.
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