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STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
AFFIDAVIT REGARDING CLIENT/RESIDENT CASH RESOURCES
This form is intended to ensure that all licensed facilities comply with statutory bonding requirements set forth in
California Health and Safety Code Chapter 3, Article 6, Section 1560, Chapter 3.1, Article 6, Section
1568.021and Chapter 3.2, Article 6, Section 1569.60.
California Health and Safety Code Chapter 3, Article 6, Section 1560, requires that applicants/licensees who handle or will handle monies
of clients of Community
Care Facilities (CCF’s) must be bonded for not less than $1,000.00. However, the provisions of this section do not
apply if the applicant/licensee meets both of the following: (a) operates a community care facility which is licensed to care for children
including but not limited to a foster family home; and (b) handles or will handle monies of persons within the community care facility in
amounts less than fifty dollars ($50) per person and less than five hundred dollars ($500) for all persons per month.
California Health and Safety Code Chapter 3.1 Article 6, Section 1568.021 and Chapter 3.2, Article 6, Section 1569.60 requires that
applicants/licensees of licensed Residential
Care Facilities For The Elderly (RCFE) and Residential Care Facilities For the Chronically Ill
(RCF-CI) that handle or will handle monies of residents must be bonded for not less than $1,000.00. However, the provisions of this
section do not apply if the applicant/licensee handles or will handle monies of persons within the facility in amounts less than fifty dollars
($50) per person and less than five hundred dollars ($500) for all persons per month.
Facilities that handle client/resident cash resources must certify that the facility does not need a bond or that a
bond is required and the amount of the bond. This form is required on new applications, renewal of licenses or
whenever the Department deems it necessary to revaluate the bonding need of a facility.
In accordance with the above provisions of California Health and Safety Code:
I(We) _
Name(s)
_______________________________________________________________________________________________________
As applicant(s) for or licensee(s) of
________________________________________________________________________________
Name of Facility
Located
______________________________________________________________________________________________________
Street
City
County
Certify that I (We):
Operate a CCF, RCFE or RCF-CI and provide care for:
Children (0-17 years of age)
_Adults (clients) (18-59 years of age)*
Elderly (residents) (60 years and older)
And (choose 1)
The maximum amount of cash resources that I/we will handle at any one time is $
monthly.
_And I/we will not handle any cash resources of persons within the facility.
I understand that I will need to obtain and submit a bond issued by a surety company admitted to do business in this State in the amount
of $
*, naming the State of California and conditional upon my/our faithful and honest handling of the money of persons within
the facility.
*Any amount of money handled for the Adult CCF categories requires a bond (excluding RCF-CI’s). A bond is also required for all
other categories, including RCF-CI’s, unless the applicant/licensee handles less than $50 per person and less than $500 per month
for all clients/residents. While the bond coverage amount may appear to be adequate, the licensee must evaluate the amount
periodically. The applicant/licensee will need to plan for bond coverage that sufficiently covers periods when the balance of funds
handled is greater than normal. For example, prior to Christmas or summer vacations the balances of clients'/residents' funds tend
to be larger than during the rest of the year.
If a bond is required, refer to the following table for the amount of bond coverage that is required:
AMOUNT SAFEGUARDED
PER MONTH
$ 750.00 or less
$ 751.00 to 1,500.00
$1,501.00 to 2,500.00
BOND REQUIRED
$1,000.00
$2,000.00
$3,000.00
Every additional increment of $1,000.00 or fraction thereof shall require an additional $1,000.00 on the bond.
I (We) also certify that:
I/we shall submit a new affidavit (LIC 400) and bond (LIC 402) to the licensing agency prior to handling amounts of clients’/residents’ cash
resources in excess of the current bond.
I/we will maintain adequate safeguards and accurate records of all cash resources entrusted to the facility, in accordance with regulations
of the State Department of Social Services.
I/we shall maintain a current surety bond at all times when handling client/resident personal cash resources.
I/WE DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS FORM AND ANY ACCOMPANYING
ATTACHMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. IN MAKING THESE STATEMENTS, I/WE REALIZE THAT
WILLFULLY SUBMITTING FALSE STATEMENTS CONSTITUTES GROUNDS FOR THE SUSPENSION OR REVOCATION OF
MY/OUR LICENSE.
Date Signature Of Applicant Or Licensee
License Number (if applicable)
Date
Signature Of Applicant Or Licensee License Number (if applicable)
