Who signs the HCS 9165?
Every board member signs their own form. HCS 281 says one form is needed for each member of the Board of Directors. Future board members too. A person who will join the board must sign one before they join (HCS 281 A7).Each person must read, complete, and sign the statement (HCS 9165). One person cannot sign for the whole board.
What the form asks
1. Home Care Organization name
2. Home Care Organization number (if known)
3. Board member name
4. Telephone
5–8. Board member home address, city, state, ZIP
9–10. Signature and date
By signing, the person says they understand their duties as a board member. They also know the agency must follow Health and Safety Code Division 2, Chapter 13. CDSS enforces it.
Do I need this form?
Only if your business has a board of directors (HCS 281 says "if applicable"). Corporations have boards. LLCs usually have members or managers instead.
One-person corporation? If you are the only director, you sign one form. Eligibility matters. CDSS will not license a corporation with an ineligible board member, executive director, or officer. Eligibility is set by HSC §§1796.40 and 1796.41 (HSC §1796.33(b)). Check before you add someone.