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STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
DESIGNATION OF FACILITY RESPONSIBILITY
Licensed facilities are required to have an authorized person continuously present at the facility during operational hours to
represent the facility and to accept licensing reports. Licensees shall use this form to delegate the above authority to
appropriate staff. Applicants/licensees who are corporations shall attach board resolutions authorizing this delegation.
Facility Name _______________________________________________________________
Date ____________________________
Facility Number _____________________________________________________________
Facility Address _____________________________________________________________
Phone___________________________
City ______________________________________________________________________
County __________________________
In the event of my absence I designate ___________________________________________________________________.
He/She is
NAME
authorized to receive any documents including reports of inspections and consultations, accusations and civil and administrative
processes on my behalf at the above-named facility.
When delegating authority to appropriate staff, Residential Care Facilities for the Elderly shall comply with CCR Title 22, Division 6 Section
87564. Child Care Centers shall comply with CCR Title 22, Division 12 Section 101215.1 and other licensed facilities shall comply with
CCR Title 22, Division 6 Section 80064.
I (We) shall notify the licensing agency, in writing, within 10 days of any change in the above authorization.
Signature of applicants/licensees
Title
Address
City County Zip
LIC 308 (11/02) (PUBLIC)
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