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Get lic 9282 2002-2024

STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DESIGNATION OF FACILITY RESPONSIBILITY Licensed facilities are required to have an authorized person continuously present at the facility during operational hours to represent the facility and to accept licensing reports. Licensees shall use this form to delegate the above authority to appropriate staff* Applicants/licensees who are corporations shall attach board resolutions authorizing this delegation* Facility Name Date Facility Number Facility Address Phone City County In the event of my absence I designate. He/She is NAME authorized to receive any documents including reports of inspections and consultations accusations and civil and administrative processes on my behalf at the above-named facility. When delegating authority to appropriate staff Residential Care Facilities for the Elderly shall comply with CCR Title 22 Division 6 Section 87564. Child Care Centers shall comply with CCR Title 22 Division 12 Section 101215. 1 and other licensed facilities shall comply with CCR Title 22 Division 6 Section 80064. I We shall notify the licensing agency in writing within 10 days of any change in the above authorization* Signature of applicants/licensees VP of Programs and Community Dev* Title 1922 The Alameda 3rd Floor Address San Jose CA Santa Clara County 95126 City County Zip LIC 308 11/02 PUBLIC. Licensees shall use this form to delegate the above authority to appropriate staff* Applicants/licensees who are corporations shall attach board resolutions authorizing this delegation* Facility Name Date Facility Number Facility Address Phone City County In the event of my absence I designate. He/She is NAME authorized to receive any documents including reports of inspections and consultations accusations and civil and administrative processes on my behalf at the above-named facility. He/She is NAME authorized to receive any documents including reports of inspections and consultations accusations and civil and administrative processes on my behalf at the above-named facility. When delegating authority to appropriate staff Residential Care Facilities for the Elderly shall comply with CCR Title 22 Division 6 Section 87564. When delegating authority to appropriate staff Residential Care Facilities for the Elderly shall comply with CCR Title 22 Division 6 Section 87564. Child Care Centers shall comply with CCR Title 22 Division 12 Section 101215. 1 and other licensed facilities shall comply with CCR Title 22 Division 6 Section 80064. Child Care Centers shall comply with CCR Title 22 Division 12 Section 101215. 1 and other licensed facilities shall comply with CCR Title 22 Division 6 Section 80064. I We shall notify the licensing agency in writing within 10 days of any change in the above authorization* Signature of applicants/licensees VP of Programs and Community Dev* Title 1922 The Alameda 3rd Floor Address San Jose CA Santa Clara County 95126 City County Zip LIC 308 11/02 PUBLIC. .

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