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Section A — Licensing Application Forms ~15 min

HCS 9165 Board Member Form (California Home Care — Corp/Nonprofit Only)

The HCS 9165 is a signed acknowledgment that your Corporation's Board of Directors understands their legal duties regarding this home care license. If you are a Sole Proprietor or an LLC, you can safely skip this step!

Why Does the State Need the HCS 9165?

When you form a Corporation, the law treats the business as its own separate "person." The Board of Directors are the people who steer that ship.

The California Department of Social Services (CDSS) uses the HCS 9165 to explicitly remind the Board that they cannot just be silent investors—they are legally on the hook to make sure the agency follows state care laws, maintains the proper surety bonds, and operates ethically.

Who actually signs this?

You do not need every single board member to sign this form. The state requires it to be signed by either the President of the Board or the Secretary of the Board, signing on behalf of the entire group.

What if I am the only person in my Corporation?

If you formed a Corporation and you are the sole owner, you are likely acting as the President, Secretary, and the sole member of the Board of Directors. That is perfectly fine! You will just sign this form yourself in your capacity as the Board President.

Common Mistakes to Avoid

  • 1LLC owners filling this out. LLCs are governed by "Members" or "Managers", not a Board of Directors, so this form does not apply to them.
  • 2Having a standard administrative employee sign this form. It must be signed by an official corporate officer (President or Secretary).

Tips

  • Keep a copy of this signed form in your corporate binder alongside your bylaws and board meeting minutes, as it is an official corporate action.

What You Need to Do

  1. 1
    Confirm that your business is structured as a Corporation
  2. 2
    Verify who holds the title of Board President or Secretary
  3. 3
    Complete the data fields above
  4. 4
    Generate, print, and have the President/Secretary sign the HCS 9165

Information You Will Need

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

Name of Corporation

The exact legal name of your Inc. or Corp.

Required
Name of Facility / Home Care Organization

Your "Doing Business As" name, if different from the Corporation name.

Required
Facility Address
Required
Name of Board President or Secretary
Required
Title of Signer

Only the President or Secretary may sign this specific document.

Required

Documents Needed

  • HCS 9165 — Board of Directors Statement (pre-filled)
    RequiredPDF · Max 10MB

Official Resources

Want us to handle this for you?

Our licensing team knows this form inside and out. For $999, 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.

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