Form Hcs 001 - Home Care Organization Suboffice Request
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2CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HOME CARE SERVICES BUREAU
HOME CARE ORGANIZATION SUBOFFICE REQUEST
This form must be completed by all Home Care Organizations who wish to operate a suboffice. One form must be submitted for each suboffice
location. A suboffice is defined in Section 90-000(s)(5) of the written directive and the administrative responsibilities are outlined in Section 90-
030. If more space is required, attach additional sheet and please type or print clearly. For instructions on how to complete this form, refer to
page two.
REQUEST TYPE
I
I
I
I
Initial
Renewal
Change of Ownership
Update
A. HOME CARE ORGANIZATION INFORMATION
CITY
B. SUBOFFICE INFORMATION
CITY
STREET ADDRESS
OPERATING DAYS AND OPERATING HOURS (no more than 24 hours within a seven calendar-day period)
C. SUBOFFICE DESIGNEE
D. QUESTIONS (if more space is needed, please attach a separate sheet.)
1. What is the primary purpose for the suboffice?
2. How will the Home Care Organization ensure the following:
a. No full-time staff
b. No permanently stored records with confidential client and/or Home Care Aide information
I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS FORM ARE CORRECT TO
THE BEST OF MY KNOWLEDGE
COUNTY WHERE SIGNED
DATE
HOME CARE ORGANIZATION LICENSEE SIGNATURE
HCS 001 (12/15)
PAGE 1 OF 2
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