STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
SURETY BOND
(Original sent to Regional Office)
Applicant/Licensee Name:
____________________________________________________________________________________
Address:
__________________________________________________________________________________________________
Bonding Company:
__________________________________________________________________________________________
Address:
____________________________________________________________ __________________________
Local Agent Name:
____________________________________________________ ____________________________
The addresses shown above for licensee and bonding company will be used
for service of notices, papers, and other documents.
BE IT KNOWN THAT:
Licensee, as Principal, and Bonding Company, as Surety, are held and firmly bound to the State of California, as beneficiary, in the
amount of $
______________________(______________________________________________________)
for the payment of which
the principal and surety bind themselves, their respective heirs, successors and assigns, jointly and severally.
WHEREAS Health and Safety Code sections 1560, 1568.021, and 1569.60 each require certain applicants for licenses to file with the
State Department of Social Services a surety bond; and
WHEREAS the licensee has applied to operate an
(check all that apply):
Adult Residential, Adult Day Programs or Social Rehabilitation Facility, and the licensee handles client/resident funds in any
amount; or
Foster Family Home, Foster Family Agency, Group Home, Small Family Home, Residential Care Facility for Persons with
Chronic, Life-Threatening Illness, or Residential Care Facility for the Elderly, and the licensee handles funds of $50 or more
per client/resident or $500 or more for all clients/ residents in any month;
NOW, THEREFORE, the surety is liable on this bond in the event that the principal fails to handle faithfully and honestly the money of
facility clients/residents.
The facility covered by this bond is:
Facility Name:
________________________________________________________________________________________
Facility Address:
______________________________________________________________________________________
Facility License Number (if facility is currently licensed):
________________________________________________________
(If other facilities are covered by this bond, specify on a separate, attached page the name, address, facility license number, and
bond amount for each facility.)
Every person injured as a result of any unfaithful or dishonest handling of client money may bring an action in a proper court on the
bond for the amount of damage suffered thereby to the extent covered by the bond.
The aggregate liability of the Surety for all claims against this bond shall not exceed the amount of the bond, shown above.
This bond may be canceled by the Surety in accordance with Code of Civil Procedure section 996.030, and notice of cancellation must
be sent in accordance with Code of Civil Procedure section 996.320. This bond is effective
________________________________,
and remains in effect as long as the license is valid.
I certify under penalty of perjury under the laws of the State of California that the information provided on this page and on any
attachments is true and correct.
LIC 402 (8/04) (PUBLIC)
BONDING COMPANY SIGNATURE: BOND NUMBER: DATE:
T
____________
elephone #:
T
__________
elephone #:
