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Get CA HHSA Form LIC 301E 2003

How do you know this person LIC 301E 7/03 Zip 3. Please give your opinion of this person s character. STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING REFERENCE REQUEST FOR To operate or work in facility type You must enter your full name and facility type before you give this form to your reference for completion* The above named person has applied to operate work or reside in a community care facility serving the client group indicated above. This person has selected you to write a reference statement on his/her behalf* If you work at the facility are a client of the facility or are related to this person in any way you may not complete this reference statement. Please complete the entire form* Your honest reply will help us ensure high quality care in our licensed facilities. Your Name Street Address City Day Time Telephone Number State 1. How long have you known the person you are writing this reference for 2. 4. Please describe any interaction you have observed between this person and the client group he/she is requesting to work with. For example Clients may be children developmentally disabled children or adults mentally impaired adults or elderly. 5. Please add any comments you feel are relevant about this person and his/her desire to work in a community care facility. STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING REFERENCE REQUEST FOR To operate or work in facility type You must enter your full name and facility type before you give this form to your reference for completion* The above named person has applied to operate work or reside in a community care facility serving the client group indicated above. This person has selected you to write a reference statement on his/her behalf* If you work at the facility are a client of the facility or are related to this person in any way you may not complete this reference statement. This person has selected you to write a reference statement on his/her behalf* If you work at the facility are a client of the facility or are related to this person in any way you may not complete this reference statement. Please complete the entire form* Your honest reply will help us ensure high quality care in our licensed facilities. Please complete the entire form* Your honest reply will help us ensure high quality care in our licensed facilities. Your Name Street Address City Day Time Telephone Number State 1. How long have you known the person you are writing this reference for 2. 4. Please describe any interaction you have observed between this person and the client group he/she is requesting to work with. For example Clients may be children developmentally disabled children or adults mentally impaired adults or elderly. For example Clients may be children developmentally disabled children or adults mentally impaired adults or elderly. 5. Please add any comments you feel are relevant about this person and his/her desire to work in a community care facility. .

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