Form LIC 165. Board Of Directors Statement - California

Form LIC 165 is a statement form used in California by the Board of Directors of a licensed facility or organization. Its main purpose is to provide a formal statement from the Board of Directors affirming their support and responsibility for the operations and compliance of the facility.

The form consists of sections where the Board of Directors provides their official statement, including their commitment to ensuring compliance with applicable laws, regulations, and licensing requirements. It may also include details about the structure and members of the Board of Directors.

It is important for the Board of Directors to fill out this form accurately and truthfully, as it signifies their acknowledgment of their role and responsibilities in overseeing the facility's operations. This statement helps demonstrate the facility's commitment to maintaining high standards of care and compliance.

Application Example: When a licensed facility or organization in California undergoes a licensing renewal process, the Board of Directors may be required to complete Form LIC 165. By submitting this form, they provide an official statement affirming their commitment to compliance and accountability.

Related Forms: Form LIC 200A, the Facility Evaluation Report, is a related form used during the inspection and evaluation of licensed facilities. Form LIC 165 focuses specifically on the formal statement from the Board of Directors, while Form LIC 200A provides an assessment report.