California Code of Regulations › Title 17 - Public Health › Division 2 - Health and Welfare Agency-Department of Developmental Services Regulations › Chapter 3 - Community Services › Subchapter 2 - Vendorization › Article 2 - Vendorization Process › Section 54310 - Vendor Application Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An applicant who desires to be vendored
					 shall submit Form DS 1890 (7/2011), entitled Vendor Application, and the
					 information specified in (1) through (10) below, to the vendoring regional
					 center.
(1) Applicant's name, including the
					 name of any governing body or management organization;
(2) Applicant's Social Security Number,
					 Federal Tax ID number, or a copy of any document accepted by the federal
					 government which establishes identity of applicant;
(3) Applicant's mailing address;
(4) Address of service, if
					 applicable;
(5) Name of family
					 member, owner or executive director, as applicable;
(6) Types of service to be
					 provided;
(7) Telephone
					 number;
(8) Facility capacity, if
					 applicable;
(9) Identification of
					 the type of consultants, subcontractors and community resources to be used by
					 the vendor as part of its service.
(10) Copies of:
(A) Any license, credential, registration,
					 certificate or permit required for the performance or operation of the service,
					 or proof of application for such document;
(B) Any academic degree required for
					 performance or operation of the service;
(C) Any waiver from licensure, registration,
					 certification, credential, or permit from the responsible controlling
					 agency;
(D) The proposed or
					 existing program design as required in Sections
					 56712 and
					 56762 of these regulations, if
					 applicable, for applicants seeking vendorization as community-based day
					 programs;
(E) The proposed or
					 existing staff qualifications and duty statements as required in Sections
					 56722 and
					 56724 of these regulations for
					 applicants seeking vendorization as community-based day programs;
(F) The proposed or existing service design
					 as required in Section
					 56780 of these regulations for
					 applicants seeking vendorization as in-home respite service agencies;
(G) The proposed or existing program design
					 as required in Section
					 58811 of these regulations for
					 applicants seeking vendorization as habilitation service providers;
(H) The proposed or existing staff
					 qualifications and duty statements as required in Sections
					 56790 and
					 56792 of these regulations for
					 applicants seeking vendorization as in-home respite services
					 agencies;
(I) The proposed service
					 design as required in Sections
					 58630 and
					 58631 of these regulations for
					 applicants seeking vendorization to provide supported living service;
(J) The signed Home and Community-Based
					 Services Provider Agreement (6/99) with the Department of Health Services,
					 obtainable from the regional centers as part of the vendorization packet, for
					 those applicants whose proposed service is eligible for Medi-Cal reimbursement;
					 and
(K) The proposed program design
					 as required by Subchapter 4.1, Section
					 56084 for those applicants seeking
					 vendorization as a family home agency (FHA).