Licensing Information (Home Care Organization Licensee Applicant Information) {HCS 215}

HCS 215 - HOME CARE ORGANIZATION LICENSEE APPLICANT INFORMATION. This form is required by the California Department of Social Services for individuals applying to operate or represent a licensed Home Care Organization. Applicants must provide identifying information, including name, address, driver’s license or ID, and any other names used. The form also collects prior licensure and disciplinary history involving community care, health facilities, child care, or home care organizations, including revocations, denials, or pending actions. Applicants must disclose past or present roles as administrators, partners, officers, directors, or beneficial owners holding 10% or more interest in related facilities, as well as any TrustLine registration. The form must be signed under penalty of perjury and accompanies the organization’s license application. www.FormsWorkflow.com