License Application

We are happy you have chosen us to handle your license application. The form below has been designed to help you provide us the necessary information in an organized simple way.
Thee are a few forms that you must complete on your own
LIC 215
LIC 501
LIC 508
LIC 503

The Property	You must first search to see if your property is within 300 ft of another ARF. Search Here
Component 1	Complete the component one orientation
3x Operating Expenses	Licensing requires you to have three times your operating expenses in the bank. If you are operating a Regional Center level 4i facility with four clients. Your income is $9,288 per client per month. That means you would gross $37,152.00 per month with four clients. Licensing figures your expenses will equal your income. So licensing wants to see an average daily balance of $114,56.00 on three months of bank statements. Check Regional Center Facility Rates
Financial Verification	LIC 404
Supplemental Financial Info.If LLC or Corp complete Part II only.	Supplmental Financial
Balance Sheet List only Assets of LLC or Corp. If new Corp that is just the money in the bank.	LIC 403
Balance Sheet Supplemental. Only list assets and liabilities of corp. Most new Corps only have money in the bank and no liabilities.	Balance Sheet Supplemental
Must be completed by applicant.	LIC 215 Applicant Information
Personnel Record Form to be completed by all staff who work in the facility and the applicant.	LIC 501 Personnel Record
Criminal Record Statement to be completed by the applicant and all staff.	LIC 508
Surety Bond	Contact NEK Insurance at 800.367.6354
Emergency Disaster Plan to be completed by applicant.	LIC 610D
Facility Sketch	To be completed by the applicant. We can do this for you for an additional fee.
Community Resources	Applicant to develop a list of community resources.

License Application Detail

Completion of this form is required for us to prepare your application.

Name of Licensee

This is the name of the person who holds the license. The licensee may or may not be the administrator,

Entity that holds the license such as Corp.

An entity that holds the license. Most people use an LLC or Corporation.

Upload Articles of Incorporation and Bylaws

Max. file size: 80 MB.

Name of Facility

You can name the facility any name you want. It does not have to be the name of the corporation. Consider using the street name e.g. Sepulveda Residential.

Name of the Administrator

The administrator must hold a state-issued Administrator Certificate to operate an ARF for clients ages 18-59. The administrator does not have to be an owner or licensee.

Enter Email Confirm Email

Phone

Address of Facility

Street Address Address Line 2 City State ZIP Code

The property that is being licensed

Malling Address

Street Address Address Line 2 City State ZIP Code

Where you receive correspondence associated with your facility.

Requested Capacity(Required)

Please enter a number from 1 to 6.

The number of clients in the facility. Regional Center requires each resident to have their room. Ir you are working with Mental Health clients or Veterans, you may have two clients per room. If you request more than 6 you will need to obtain a conditional use permit from the building department.

Number of Non Ambulatory Clients(Required)

Please enter a number from 0 to 3.

Non-Ambulatory means the individual requires mechanical aids such as a walker or wheelchair to exit the facility in an emergency. Also includes individuals who are unable to respond to oral instruction in an emergency.

Property Ownership

Own

Rent or Lease

If leasing provide the name of the property owner.

Address of Property Owner if Leasing

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please upload copy of Title or Lease.(Required)

Max. file size: 80 MB.

A title or Lease showing control of the property is required.

Was the property previously licensed?(Required)

Yes

If Facility was previously licensed please provide the license number and name of facility.

List past or current facility you hold ownership.

If you have previously operated a residential care or healthcare facility, please list the name and license number.

Documents Upload(Required)

Drop files here or

Accepted file types: pdf, jpg, Max. file size: 80 MB.

Please upload all required Documents including: Administrator Certificate, Component 1 Orientation Certificate, First AID Certificate for Applicant and all staff, Health Screening LIC 503.