Section A — Licensing Application Forms ~30 min

How to Fill Out the HCS 215 Form (Licensee/Applicant Information)

While the HCS 200 is about your business, the HCS 215 is about YOU. The state requires a personal disclosure form for the individuals in charge to ensure they have a clean background and track record in the care industry. You must be completely transparent about any past disciplinary actions or other care facilities you have been involved with.

Demystifying the HCS 215 Form

The state uses this form to vet the actual human beings running the Home Care Organization. Here is how to navigate the trickiest parts:

Who exactly needs to fill this out?

This is the most common point of confusion. The requirement depends entirely on how your business is structured:

  • Sole Proprietorship: Only you (the owner) fill this out.
  • Partnership: Every general partner must fill out their own separate HCS 215.
  • Corporation / LLC: The Chief Executive Officer (CEO) or a formally Authorized Representative must fill this out.
Home Address vs. Business Address

Unlike the HCS 200, the state explicitly wants your personal home address and personal phone number here. They are verifying your individual identity, not the office location.

Status of Disciplinary Actions

Read these questions very carefully. The state is asking if you have ever had a license revoked or denied in a variety of care settings (child care, elderly care, health clinics, etc.). Honesty is critical here—the state will cross-reference this with their internal databases and background checks. A past mistake does not automatically disqualify you, but lying about it almost certainly will.

Business Experience

The state wants to know if you have worked in the home care industry within the last 5 years, or if you have owned any business within the last 3 years. If you answer yes, you just need to provide basic details (dates, title, reason for leaving).

Common Mistakes to Avoid

  • 1Using the business office address instead of your personal home address.
  • 2Only having one partner fill out the form when the business is structured as a Partnership (every partner needs one).
  • 3Leaving the "Status of Disciplinary Actions" section blank. You must explicitly check "No" if you have no past actions.

Tips

  • If you have multiple people who need to submit an HCS 215 (like multiple partners), generate and print multiple copies of this form.
  • Providing your Social Security Number is technically voluntary for ID purposes on this specific form, but providing your Driver's License number is mandatory.

What You Need to Do

  1. 1
    Determine exactly who in your organization needs to submit this form based on your legal entity type
  2. 2
    Fill out the per-person HCS 215 form for each required individual below

    Each owner (10%+) and designee needs their own HCS 215. Fill in DOB, DL#, home address, and disciplinary disclosures for each person.

  3. 3
    Complete the general applicant fields above (used as defaults)
  4. 4
    Generate, print, and sign a separate HCS 215 for each person

    Sign each form with blue or black ink. Each person gets their own signed copy.

Information You Will Need

Have these details ready before you sit down to fill this out:

Full Legal Name

Your personal legal name (First, Middle, Last).

Required
Date of Birth

Format: MM/DD/YYYY

Required
Title within the Home Care Organization
Required
Driver's License Number or State ID

Required to verify your identity.

Required
Personal Home Street Address

Must be your actual residential address. Do not use the business office address here.

Required
Personal Telephone Number
Required
A. Have you ever had disciplinary action taken against you regarding a licensed care facility?

This includes licenses revoked, denied, or forfeited for clinics, elderly care, child care, or home care.

Required
B. Do you have prior or present service as an Administrator, Partner, or Officer in a care facility?
Required
C. Have you ever held a 10% or more ownership interest in a care facility?
Required
D. Have you ever been registered with the Trustline Registry Program?
Required
Have you worked in the Home Care Services industry within the last 5 years?
Required
Have you owned or operated ANY business within the last 3 years?
Required
County Where Signed

What California county are you physically sitting in when you sign this application?

Required

Documents Needed

  • HCS 215 — Licensee Applicant Information (pre-filled)
    RequiredPDF · Max 10MB

Official Resources

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How to Fill Out the HCS 200 Form
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HCS 308 Form Guide — Designee Responsibility