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Section A — Licensing Application Forms ~30 min

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

The HCS 200 is about your business. The HCS 215 is about the people behind it. Be honest about any past license problems.

Who fills out an HCS 215?

HCS 281 says every applicant does. That means: each individual applicant, each partner in a partnership, the CEO of a corporation, each person who owns 10% or more of a corporation or LLC, and the manager of a manager-managed LLC.

  • Sole owner: You.
  • Partnership: Each partner fills out their own.
  • Corporation: The CEO, plus each person who owns 10% or more.
  • LLC: Each person who owns 10% or more. If a manager runs the LLC, the manager too.
Note: Our people tracker may also list designees. HCS 281 does not ask designees for an HCS 215. But do add your CEO or LLC manager, even if they own less than 10%.

What the form asks

Identifying information
  • Full name and title at the agency.
  • ID type and number. CDSS takes any of these:
* California driver's license

* California ID card

* Permanent Resident Card

* ID card from another state (write which state)

  • Social Security Number. This is voluntary. It is only used to identify you.
  • Other names you have used (like a maiden name).
  • Date of birth and home address.
  • Telephone: HCS 281 says to enter the HCO's phone number here.
Prior licensure status
  • A. Discipline. Has a license or registration ever been revoked, denied, or acted on? This covers clinics, care facilities, child care, HCOs, home care aides, and TrustLine. If yes, fill in A1 to A5.
  • B. Past jobs. Have you been an administrator, general partner, corporate officer, or director of a care facility or HCO? If yes, fill in B1 to B3.
  • C. Ownership. Have you owned 10% or more of a care facility or HCO? If yes, fill in C1 to C3.
  • D. TrustLine. Have you ever been on the TrustLine registry?

The law requires these disclosures (HSC §1796.37(a)(9)–(10)). A past problem does not always mean you are denied. Leaving it out can cause more trouble.

Signature

You sign that your answers are true "under penalty of perjury." Add the date and the county where you signed.

Common Mistakes to Avoid

  • 1Skipping the CEO or the manager of a manager-managed LLC. They must file one too (HCS 281 A2).
  • 2Only one partner filling it out. Each partner needs their own.
  • 3Putting a personal cell in "Telephone." HCS 281 says to use the HCO's number.
  • 4Leaving A, B, C, or D blank. Check "No" if the answer is no.

Tips

  • More than one person? Make a separate HCS 215 for each one.
  • Your Social Security Number is voluntary on this form. Your ID type and number are not.

What You Need to Do

  1. 1
    Determine exactly who in your organization needs to submit this form based on your legal entity type

    HCS 281 A2: each individual applicant, each partner, the CEO, each 10%+ owner, and the manager of a manager-managed LLC.

  2. 2
    Fill out the per-person HCS 215 form for each required individual below

    Add your CEO or LLC manager too, even if they own less than 10%.

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

    Each person signs and dates their own form and adds the county where signed.

Information You Will Need

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

Name

Your full legal name (first, middle, last).

Required
Title

Your title at the Home Care Organization.

Required
Date of Birth
Required
Other Name(s) Used

Any other names you have used (marriage, adoption, and so on).

Identity Document Type
Required
Issuing State (only for an ID from another state)
Identity Document Number

The number on the ID you picked above.

Required
Home Address

Your home address. Not the office address.

Required
Telephone Number (your HCO's phone)

HCS 281 says to enter the Home Care Organization's phone number here.

Required
A. Have you ever had a license or registration revoked, denied, excluded, forfeited, or other discipline? Or is a legal action in progress?

Covers clinics, health and care facilities, child care, HCOs, home care aides, and TrustLine. If yes, fill in A1–A5.

Required
B. Have you served as an administrator, general partner, corporate officer, or director of a care facility or HCO?

Past or present. If yes, fill in B1–B3.

Required
C. Have you ever held a 10% or more ownership interest in a care facility or HCO?

Past or present. If yes, fill in C1–C3.

Required
D. Have you ever been registered with the TrustLine registry program?
Required
County Where Signed

The county you are in when you sign.

Required

Documents Needed

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

Official Resources

Want us to handle this for you?

Our licensing team knows this form inside and out. We fill out every form, check every box, and submit the whole packet to CDSS on your behalf. You just answer a few simple questions.

Get Full Licensing Help Do It Yourself (Free)
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How to Fill Out the HCS 200 Form
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HCS 308 Form Guide — Designee Responsibility
John Helmy

Researched and reviewed by

John Helmy, Founder of HomeCareAtlas

Building tools and resources to help home care agency owners navigate licensing, compliance, and growth.