Extension Request rev 10 2019 1 of 2
REQUEST FOR EXTENSION OF EXAMINATION/APPLICATION
Per Title 22, California Code of Regulations section 87064.2(i) (Short-Term Residential
Therapeutic Programs); 84064.2(i) (Group Homes); 85064.2(i) (Adult Residential Facilities); or
87406(i) (Residential Care Facilities for the Elderly):
“Time deadlines … may be extended up to sixty (60) days in total for good cause as
determined by the Department. Any request for an extension of time shall be made in
writing to the Administrator Certification Section Manager within sixty (60) days of
completing the Initial Certification Training Program and shall contain a statement of all
facts the applicant believes constitute good cause to extend a time deadline.
Good cause may include death of an immediate family member, required fulfillment of
military service or other civic duty, or another unavoidable and verifiable event as
determined by the Department. Failure of the exam shall not constitute good cause for an
extension.”
Name:
(First Name) (Middle Name) (Last Name)
Mailing Address:
Phone Number: SSN:
E-Mail Address: DOB:
Certificate Number (if applicable):
Please check one of the following boxes and provide an explanation in detail of the
circumstances in which you could not pass your exam/submit your application by the time
deadline. Describe what steps will be taken or have been taken to comply with the deadline.
I am unable to comply with regulation section 87064.2(b)(2) for Short-Term Residential
Therapeutic Programs, 84064.2(b)(2) for Group Homes, 85064.2(b)(2) for Adult
Residential Facilities, or 87406(b)(2) for Residential Care Facilities for the Elderly which
state that to receive his/her certificate an applicant shall:
“Unless exempted by Section 87406(a)(1) or (a)(2), pass a written exam developed and
administered by the Department within sixty (60) days of completion of an Initial
Certification Training Program and within three (3) attempts.”
I am unable to comply with regulation section 87064.2(b)(3) for Short-Term Residential
Therapeutic Programs, 84064.2(b)(3) for Group Homes, 85064.2(b)(3) for Adult
Residential Facilities, or 87406(b)(3) for Residential Care Facilities for the Elderly which
state that to receive his/her certificate an applicant shall:
“Submit a completed Application for Administrator Certification form LIC 9214 to the
Department’s Administrator Certification Section within thirty (30) days of being notified of
having passed the exam, or [for RCFE applicants] if the applicant is exempt from taking
the written exam, within thirty (30) days of completing the Initial Certification Training
Program.”
Extension Request rev 7 19 2 of 2
Request has been approved OR denied by:
Date:
Notes:
Specify in detail the facts that establish good cause in support of your request. (You may
attach additional pages if necessary.)
In addition to the explanation above, please submit the following with this form:
o
Copy of your Initial Certification Training Program certificate
o
Documentation supporting your good cause (e.g., copy of funeral brochure,
death certificate, plane tickets, hospital documentation), if applicable.
Applicant’s Signature: Date:
When all required documents are received, ACS will provide the applicant a written
decision either granting or denying the request for an extension. You are
encouraged to visit the Administrator Certification Section website at
http://www.cdss.ca.gov/acs for the laws, regulations, forms and other information
regarding obtaining an administrator certificate.
Extension Requests must be submitted via FAX to: (916) 654-1808
DO NOT WRITE BELOW THIS LINE
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