Form Hcs 308 - Designation Of Home Care Organization Responsibility
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1CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES BUREAU
DESIGNATION OF HOME CARE ORGANIZATION RESPONSIBILITY
Licensed Home Care Organizations are required to have a designee continuously present during operational hours to
represent the Home Care Organization, perform administrative processes, and to accept licensing reports. Home Care
Organization applicants/Home Care Organization licensees shall use this form to delegate the above authority to
appropriate staff member(s). More than one staff member may be designated on this form. Home Care Organization
applicants/Home Care Organization licensees who are corporations shall attach board resolutions authorizing this
delegation.
DATE
HOME CARE ORGANIZATION NUMBER
HOME CARE ORGANIZATION NAME
HOME CARE ORGANIZATION ADDRESS
CITY
ZIP CODE
STATE
COUNTY
AREA CODE/TELEPHONE
(
)
I understand my roles and responsibilities as a designee for the above-named Home Care Organization. I also
understand that the Home Care Organization operation is governed by laws and regulations that are enforced by the
California Department of Social Services.
PRINTED NAME OF DESIGNEES(s)
SIGNATURE OF DESIGNEES(s)
In the event of my absence I authorize the abovementioned person(s) to perform administrative processes on my behalf
at the above-named Home Care Organization, including but not limited to: managing the Home Care Organization,
responding to questions, receiving documents including reports of inspections and consultations, accusations, and civil
penalties.
When delegating authority to appropriate staff, Home Care Organizations shall comply with statute and regulations.
I (We) shall notify the Department, in writing, within 10 calendar days of any change in the above authorization.
SIGNATURE OF HOME CARE ORGANIZATION APPLICANT/ HOME CARE ORGANIZATION LICENSEE
TITLE
ZIP CODE
MAILING ADDRESS
COUNTY
STATE
CITY
HCS 308 (8/15)
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