State of California—Health and Human Services Agency
California Department of Public Health
MARK B HORTON, MD, MSPH Director
EDMUND G. BROWN JR. Governor
Home Health Agencies
Fingerprint Clearance Requirements for Owners, Administrators, and Administrator’s Designee
January 6, 2011
The purpose of this All Facilities Letter is to serve as a reminder of the criminal record clearance requirements for home health agencies licensed by the department. Pursuant to Health and Safety Code Section 1728.1(a)(2)(A) a criminal record clearance is required for the following individuals:
The owner or owners of a home health agency if the owners are individuals;
If the owner of a home health agency is a corporation, partnership or association, any person having a ten (10) percent or greater interest in that corporation, partnership or association and;
The administrator and administrator’s designee of a home health agency.
The individuals identified above are required to submit a Request for Live Scan Service: BCII 8016 form. For your convenience, a link to the BCII 8016 and a sample form is provided. The "sample form" provides instructions to assist you in correctly entering the required information. Once the form is completed, the Request for a Live Scan Service: BCII 8016 form should be taken to a live scan vendor.
1Sample Form (Completed) Request for Live Scan Service: BCII 8016(PDF)
2Request for Live Scan Service: BCII 8016 (PDF)
Please note the live scan vendor will complete the Transaction Section (gray area) of the Live Scan Service: BCII 8016 form.
Licensing and Certification Program, MS 0512, P.O. Box 997377, Sacramento, CA 95899-7377 (Internet Address: www.cdph.ca.gov)