Lic 606 Form

LIC 606 4/16 PAGE 1 OF 5 3. Other Facilities HSC 1569. 15 a 3 C - D 1569. 15 a 3 B a. Facilities Provide information for all other health residential or community care facilities owned managed or operated by the applicant licensee and/or management company located anywhere in the United States. STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES RESIDENTIAL CARE FACILITY FOR THE ELDERLY DISCLOSURE WORKSHEET Instructions This worksheet is optional and designed to assist all RCFE applicants co-applicants and licensees to comply with the disclosure requirements outlined in AB 601 Chapter 628 Statutes of 2015 which amended Health and Safety Code HSC Sections 1569. 2 1569. 15 1569. 16 1569. 50 1569. 58 and 1569. 618 and added 1569. 356. You may photocopy this worksheet if necessary. Please label all copies and attached documents clearly. Name of Facility License number if applicable Name of Applicant/Co-applicant/Licensee/Co-licensee Name of individual submitting this information Date worksheet submitted Part 1. General Information HSC 1569. 15 a 3 1569. 15 e a* This information is submitted as an Addendum to an application check one Update to a licensed facility s information If updating review Part 10. before completing worksheet. b. State type of provider For-profit provider Not-for-profit provider c* Provide the email address of record for the facility here Part 2. Evidence of Reputable and Responsible Character HSU 1569. 15 a 2 1569. 15 a 3 B a* All individuals and entities holding a beneficial ownership interest of 10 percent or more and/or with operational control of the facility are required to provide evidence regarding reputable and responsible character. Note Individuals and entities with operational control of the facility must also disclose information in Parts 5. 6. and b. Separate list is attached giving the names addresses and phone numbers of the individuals and entities who hold a 10 percent beneficial ownership in the applicant or co-applicant. Yes No or entities who have operational control of the applicant or licensee. Operational control involves control over the daily operation of the facility. Examples of individuals and entities with Executive Director 4 general partner 5 like party who is in charge of daily operations of a facility and/or 6 parent organization* d. For each individual identified in the lists called for above in Parts 2. b. and 2. c* please verify the following 1 Criminal record statements were submitted Form 508 2 Fingerprints and Form 9163 were submitted and 3 Employment history and character references were submitted Form LINC 215. Note It may take time to receive a criminal records clearance it is advised that fingerprints be submitted as early as possible. Do you have other such facilities If yes a separate list of facilities is attached including facility name address b. Parent Organizations Provide information for all other health residential or community care facilities owned managed or operated by parent organizations of the applicant licensee and/or management company and/or parent organizations of the parent organizations etc* located in California or any other state.