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Lic 400  Form

Lic 400 Form

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STATEMENTS CONSTITUTES GROUNDS FOR THE SUSPENSION OR REVOCATION OF MY/OUR LICENSE. Date LIC 400 1/99 PUBLIC Signature Of Applicant Or Licensee License Number if applicable. STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION AFFIDAVIT REGARDING CLIENT/RESIDENT CASH RESOURCES This form is intended to ensure that all licensed facilities comply with statutory bonding requirements set forth in California Health and Safety...
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