Document Upload – Get ALW

Accepted formats: PDF, JPG, PNG, Word (.doc/.docx). Fields marked Optional can be skipped. For items with multiple owners, you can select multiple files in a single upload field. Questions? Call (310) 342-0961 or email info@angelcitysenior.com.

Your Information

Your Name *

Facility Name *

Facility Legal Name (LLC or Corp, if different)

DBA (if applicable)

Your Email Address *

Facility Email Address (if different)

Your Phone Number *

Facility Phone Number (if different)

Website (if applicable)

General Documents

Current RCFE or ARF Facility License

Your active facility license. Please also have your original facility license application available as a reference.

State-Issued Driver's License & SSN Documentation

Required for all individuals with 5% or more ownership interest. You may select multiple files. For SSN, upload a separate document — do not write your SSN directly in a file name.

Federal Tax ID / EIN Letter

IRS SS-4 confirmation letter showing your Employer Identification Number

Resident Admission Agreement (Sample)

Your standard sample admission agreement for incoming residents

Declaration Page — General Liability Insurance

Declarations page from your current general liability insurance policy

Declaration Page — Worker's Compensation Insurance

Declarations page from your current worker's compensation insurance policy

Business License If city requires it

Local city or county business license, if required in your jurisdiction

NPI (National Provider Identifier)

NPI confirmation letter or documentation. If you don't have one yet, we can assist.

Lease Agreement If facility is leased

Current lease agreement for the facility property, if applicable

Brochures or Marketing Materials Optional

Any brochures, flyers, or marketing materials about your facility

House Rules

Your facility's current house rules provided to residents

Part A — LIC Forms

LIC 200 or LIC 215 (preferred) — Application

RCFE or ARF facility application form. LIC 215 is preferred if available.

LIC 309 — Administrative Organization If available

Administrative organization chart for the facility

LIC 400 or LIC 402 — Surety Bond

Current surety bond documentation for the facility

LIC 610E — Emergency Disaster Plan

Must be the newer version, signed and dated

LIC 999 — Facility Sketch (Floor Plan)

Current floor plan / facility sketch showing room layout

Part B — Policies & Supplemental

Articles of Incorporation and DBA If applicable

Articles of Incorporation and any DBA filing documentation

In-Service Training — Policies & Documentation

Any policies, training schedules, or documentation related to staff in-service training

B10

Sample Menu

A sample weekly or monthly menu for facility residents

B+

Sample Activities

Sample activities schedule or activity programming documentation

Tell Us About Your Facility

Do you have an LVN or RN on staff?

Yes No

If Yes — provide contact information, work schedule, and license number:

If No — provide contact information and contract for Home Health Agency or other agency that provides services as needed:

Alert System / Individualized Response System

Not required for facilities with 6 beds or fewer. How is staff alerted and how does staff respond to resident assistance requests? Examples: call button, phone by the bedside. Please describe your response system in detail.

Transportation Policy

Do you provide transportation? Do you only coordinate transportation? Please describe your transportation policy in detail.

Interior of Your Facility — What makes it stand out?

Please describe anything about the interior of your facility (living area) that sets it apart from others. Examples: extra-large family room for activities, dedicated area for resident visitors, etc.

Exterior of Your Facility — What makes it stand out?

Please describe anything about the exterior of your facility (yard/outdoor area) that sets it apart. Examples: large shade area under a big tree, a place for residents to garden, etc.

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