ED 4. ADA for previous quarter: SERVICE: CAPACITY: 6. Also Provides Adult Day Program Services? Yes No 8. NAME 7. SIGNATURE OF ADMINISTRATOR OR PROGRAM DIRECTOR: 9. Scheduled Number of Hours per Month: DATE: 11. LICENSE/ REGISTRATION/ 10. Date of Hire: CERTIFICATION ADMINISTRATOR PROGRAM DIRECTOR REGISTERED NURSE(s) LICENSED VOCATIONAL NURSE(s) SOCIAL WORKER(s) SOCIAL WORK ASSISTANT(s) ACTIVITY COORDINATOR AIDES PHYSICAL THERAPIST (PT) PT ASSISTANT PT AIDE(s) OCCUPATIONAL THERAPIST (OT) CE.
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How to fill out the CA ADH 0006 online
The CA ADH 0006 form, known as the Staffing/Services Arrangement, is essential for providing information about staff and services at Adult Day Health Care centers. This guide will assist you in correctly filling out the form online, ensuring that your submission is complete and accurate.
Follow the steps to complete the CA ADH 0006 online effectively.
- Press the ‘Get Form’ button to obtain the Staffing/Services Arrangement form and open it in your preferred editor.
- In Box #1, input the licensee name of your organization to identify the legal entity responsible for the center.
- In Box #2, provide the center's hours of service as defined in Health and Safety Code Section 1570.7(h). This indicates when your center operates.
- For Box #3, enter the center’s licensed capacity as detailed in your center’s ADHC license, which specifies the maximum number of participants.
- In Box #4, calculate the average daily attendance (ADA) for the previous quarter. If you are filling this out in October, total the ADA for July, August, and September, then divide by three.
- Input the center’s name in Box #5 to indicate the official name under which you operate.
- For Box #6, indicate whether the center also provides Adult Day Program services by circling ‘Yes’ or ‘No.’
- Box #7 requires the signature of the Administrator or Program Director. Enter the date to affirm that all information provided is accurate.
- In Box #8, list the names of all staff members. If any staff have approved program flexibility, note this by adding ‘(PF)’ next to their name.
- In Box #9, enter the scheduled number of hours each staff member is expected to work per month, such as 160 hours.
- In Box #10, record the hire date for each staff member, formatted as MM/DD/YY.
- In Box #11, enter the license, registration, or certification number and its expiration date for those applicable staff members.
- Finally, in Box #12, provide the names of meal and transportation providers associated with your center.
- After completing all fields, you have the option to save changes, download, print, or share the form for submission.
Complete your CA ADH 0006 online today to ensure compliance and proper documentation.
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The California Credential Authorizing Administrative Services allows qualified individuals to serve in administrative roles within California’s educational system. This credential is essential for those seeking leadership positions, as it verifies your capability to manage educational programs effectively. For details on obtaining this credential, refer to the comprehensive guidelines provided in the CA ADH 0006.
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