___________
State of California — Health and Human Services Agency Department of Health Care Services
Licensing and Certification Section, MS 2600
P.O. Box 997413
Sacramento, CA 95899-7413
A-4 – DESIGNATION OF ADMINISTRATIVE RESPONSIBILITY
Corporations shall attach board resolutions authorizing a delegation to the Program Director and/or
Administrator or other appropriate staff.
1. Legal Entity Name:
2. Program Name:
3. Program Address:
4. City: County:
5. Telephone: ( )
6.
(Name of person authorized by legal entity)
(Name of person authorized by legal entity)
Zip Code:
E-mail Address:
Title
Title
is hereby designated as administrator, program manager, or agent of the above-named program and is
authorized to receive at the above named program on my behalf, any documents including reports of
inspections and consultations, accusations, and civil and administrative processes.
PER SECTION 10561(C)(3), I WILL NOTIFY THE DEPARTMENT OF HEALTH CARE SERVICES, WITHIN 10
WORKING DAYS OF ANY CHANGE OF THE ADMINISTRATOR OF THE FACILITY.
7.
8. Title:
Signature of legal entity officer/member
9. Address:
10. City: County: Zip Code:
DHCS 5085 (01/17)
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