California Department of Social Services (CDSS) Community Care Licensing Division — Administrative Organization (LIC 309) Completed Form Examples and Samples
Find clear, filled-out examples and samples of the California Department of Social Services (CDSS) LIC 309 form. Our guide helps you correctly complete the Administrative Organization form for your Community Care Licensing application.
California LIC 309 Form Example for an Adult Residential Facility
How this form was filled:
This is an example of a completed LIC 309 form for a new corporate-owned Adult Residential Facility (ARF). It clearly defines the licensee, the facility administrator and their qualifications, and designates who is in charge during the administrator's absence. The form is a required part of the licensing application and establishes the administrative structure and chain of command for the facility.
Information used to fill out the document:
- Facility Name: Golden Years Senior Living
- Applicant/Licensee Name: Golden Years Care, Inc.
- Facility Address: 456 Oak Avenue, Sacramento, CA 95814
- Mailing Address: 456 Oak Avenue, Sacramento, CA 95814
- Facility Telephone Number: (916) 555-0100
- Administrator Name: Jane M. Smith
- Administrator Qualifications: Certified ARF Administrator (#123456789), 10 years experience in senior care management.
- Assistant Administrator Name: Robert P. Jones
- Assistant Administrator Qualifications: 5 years experience as a lead caregiver, currently completing Administrator certification course.
- Person(s) Responsible in Administrator's Absence: Robert P. Jones (Assistant Administrator), Maria Garcia (Lead Caregiver)
- Organizational Chart: An attached document detailing the hierarchy from the Board of Directors down to all staff positions.
- Signature: Jane M. Smith
- Title of Signer: Administrator
- Date Signed: 01/15/2026
What this filled form sample shows:
- Clearly defined Licensee information for a corporate entity.
- Detailed Administrator qualifications, a key requirement for licensing.
- Specifies the chain of command for when the Administrator is absent, ensuring continuous supervision.
- References an attached organizational chart, which is a required component of the LIC 309 submission.
- Properly signed and dated near the current year (2026) for relevance.
Form specifications and details:
| Form Name: | Administrative Organization (LIC 309) |
| Use Case: | New license application for an Adult Residential Facility (ARF). |
| Issuing Agency: | California Department of Social Services (CDSS) - Community Care Licensing Division |
| Filing Requirement: | Required for new applications and when there are changes in administrative organization. |
Created: February 10, 2026 11:50 PM
