§ 87102 — Descriptions of Forms

The forms specified in subsections (j) through (l) only apply to this chapter, Chapter 8 (Residential Care Facilities for the Elderly).  The forms specified in subsections (a) through (i) also apply to the regulations in Title 22, Division 6, Chapters 5 (Group Homes) and 6 (Adult Residential Facilities).  All forms in this section are incorporated, in their entirety, by reference.

(a)  LIC 9139 (01/16) - Renewal of Continuing Education Course Approval, Administrator Certification Program.

(b)  LIC 9140 (01/16) - Request for Course Approval, Administrator Certification Program.

(c)  LIC 9140A (01/16) - Request to Add or Replace Instructor, Administrator Certification Program.

(d)  LIC 9141 (01/16) - Vendor Application/Renewal, Administrator Certification Program.

(e)  LIC 9142A (01/16) – Roster of Participants - for Vendor Use Only, Administrator Certification Program.

(f)  LIC 9142B (01/16) – Roster of Participants – for Exam Proctoring Only, Administrator Certification Program.

(g)  LIC 9163 (3/11) – Request for Live Scan Service – Community Care Licensing.

(h)  LIC 508 (7/15) Criminal Record Statement.

(i)  LIC 9214 (01/16) – Application for Administrator Certification, Administrator Certification Program.

(j)  PUB 325 (3/12) - Your Right To Make Decisions About Medical Treatment.

(k)  Core of Knowledge Training Standard (01/16) - RCFE 80-Hour Initial Certification.

(l)  PUB 475 (10/18) - Residential Care Facility for the Elderly (RCFE) Complaint Poster.

NOTE: Authority cited:  Sections 1530, 1569.616(i)(1) and 1569.30, Health and Safety Code.  Reference:  Sections 1522.41, 1562.3, 1569.267, 1569.269, 1569.33 and 1569.616, Health and Safety Code.