Fillable LIC9214 LIC 9214 - Application for Administrator Certification

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LIC9214 LIC 9214 - Application for Administrator Certification

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  • 33 check-boxes
  • 23 other fields

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Date:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
APPLICATION FOR ADMINISTRATOR CERTIFICATION
ADMINISTRATOR CERTIFICATION PROGRAM
For Office Use Only:
PRINTS TO DOJ:
DOJ C
LEARED:
Instructions: See page 2 for complete instructions.
FBI CLEARED:
(1)
Type of Application: (Check one box only. If renewing, provide certificate number
and expiration date.)
CACI:
FACILITY #:
New Renewal Certificate # Expires:
D.O. #:
(2)
Type of Program: (Check one box only; if applying for more than one certificate,
submit separate application for each.)
LIS
#:
ARF (Adult Residential Facility) GH (Group Home) RCFE (Residential Care Facility for the Elderly)
STRTP (Short Term Residential Therapeutic Program)
(3)
Applicant Information: (Please print.) Check here if any information has changed since last submittal.
Name (First, MI, Last
):
Address (Street Address, C
ity, State, Zip):
Telephone Number: Cell: E-mail:
Social Security Number:* Date of Birth: (MM/DD/YY)
(a)
Do you currently hold or
have you previously
held a license, certification or other
approval as a professional
in a
specified field (e.g., RN, NHA)? If
yes,
please list the type(s) of license(s) or certificate(s) and their
number(s).
(Include any
Administrator
Certificates.)
YES
NO
(b)
Do you currently hold or
have you previously
held a State-issued care facility
license? If
yes, please list the type
of license(s) and license number(s).
(Include any community care
facility
licenses.)
YES
NO
(c)
Are you currently employed or
were you previously employed by a State-licensed care facility? If
yes, please list
the facility name(s) and license number(s).
(Place an * by those where
currently
employed.)
YES
NO
(d)
Have you been the subject
of any
legal, administrative, or other action involving licensure, certification or other
approvals as specified in (a), (b), and (c) above? If
yes, please explain and provide the date(s).
(Include any
Administrative Actions.
Attach additional
pages if more space
is
needed.)
YES NO
(4)
For INITIAL APPLICANTS
ONLY, indicate when you would like your
certificate to expire. (Select one box
only.
If
you do not select
one, two years from issuance will be
used.)
Two years from date of certificate issuance.
Your
birthdate of the second calendar
y
ear from certificate issuance.
(This
irrevocable selection means your
initial
certificate term may
be for more or
less than two full
years.)
(5)
Applicant
Certification:
I
declare
that
the
foregoing
information
is
true
and
correct
to
the
best
of
my
knowledge.
Applicant
Signature:
* Optional but requested for CDSS use only to assist in verifying identity and licensing affiliations. Federal law (at Title 5 United States
Code Section 552a Note) states that: Any federal, state, or local government agency which requests an individual to disclose his
social security account number shall inform that individual whether that disclosure is mandatory or voluntary, by what statutory or
other authority such number is solicited, and what uses will be made of it.
LIC 9214 (1/19) PAGE 1 OF 2
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Instructions:
FOR ALL APPLICANTS: Use the applicable following checklist to ensure your application is complete (including all
supporting forms and fees) and submit it to: CDSS, Administrator Certification Section (ACS), 744 “P” Street,
MS 9-17-47, Sacramento, CA 95814. Keep a complete copy of your package for your records. If you have any
questions about the application process, please call the ACS at (916) 653-9300.
FOR INITIAL APPLICANTS:
To receive your Administrator Certificate, applicant shall be at least 21 years of age, have a high school diploma or
equivalent, such as a General Education Development (GED) certificate, have the required criminal record clearance (or
exemption) on file with the Department of Justice (including, for GH administrators, a Child Abuse Central Index check
clearance), and must submit the following within 30 days of receiving your congratulatory letter:
A copy of the Department’s congratulatory letter verifying a passing exam score. (Keep original for your files.)
A copy of the Department’s application deadline extension approval letter, if applicable. (Keep original for your
files.)
A completed Application for Administrator Certification (form LIC 9214 (05/16))
A check or money order for $100 payable to the Department of Social Services. Please include your
administrator certificate number on your check. Paper clip your check to your documents; do not staple or glue.
A copy of your Certificate of Completion of the Initial Certification Training Program (ICTP, provided by ICTP
vendor), or proof of applicable coursework if RCFE/NHA or GH/STRTP applicant.
A completed Criminal Record Statement (form LIC 508 (07/15))
If you have already been fingerprinted by Live Scan, a copy of the completed Request for Live Scan Service
(form LIC 9163 (12/15), signed by the Live Scan operator. (Note: You do not need to wait for your Live Scan
results before submitting your application.)
If applicable, for RCFE applicants only, a copy of your current Nursing Home Administrator license.
FOR RENEWAL APPLICANTS:
In order to maintain compliance with the provisions of the Administrator Certification Program, you are required to
maintain the criminal record clearance (or exemption), and submit the following information prior to the certificate
expiration date. Note that certificates cannot be renewed if they have been expired for more than four (4) years.
A completed Application for Administrator Certification (form LIC 9214 (05/16))
A check or money order for $100 payable to the Department of Social Services (OR for $300 if you’re renewing
after your certificate expired). Please include your administrator certificate number on your check. Paper clip
your check to your documents; do not staple or glue.
Proof of completion (e.g., copies of completion certificates from course vendors) of forty (40) hours of
continuing education (OR twenty (20) hours for RCFE/NHA certificate holders) sufficiently related by subject
matter and logic to the Core of Knowledge for your certificate type (e.g., ARF, GH, RCFE) and provided by
approved vendors per program regulations. The total units must include:
At least four (4) hours of instruction in laws, regulations, policies and procedural standards that impact your
type of care facility (e.g., ARF, GH, RCFE)
If not included in your ICTP, at least one (1) hour of instruction in cultural competency and sensitivity in
issues related to the lesbian, gay, bisexual, and transgender community
For RCFE (and RCFE/NHA) certificate holders, at least eight (8) hours in subjects related to serving
residents with Alzheimer’s Disease or other dementias
If applicable, for RCFE applicants only, a copy of your current Nursing Home Administrator license.
For applicants renewing more than two (2) years but less than four (4) years after certificate expired, proof of
completion of an additional forty (40) hours of continuing education (or 20 for RCFE/NHA certificate holders),
including an additional four (4) hours in laws, etc., and eight (8) hours in dementia subjects as detailed above.
LIC 9214 (1/19) PAGE 2 OF 2
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LIC9214 LIC 9214 - Application for Administrator Certification

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Completed 23 June 2020

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