1. (a) An applicant for approval to perform as a Quality Assurance Inspector shall apply to the department using HCD-MH 469 “Application for Quality Assurance Inspector Approval,” dated May 1989 and provided by the department. The applicant shall provide the following information:

   1. (1) Indication of whether the application is for a Quality Assurance Inspector original approval or approval renewal.
   2. (2) The name, business address and telephone number of the applicant.
   3. (3) Indication of whether the applicant is currently employed or will be employed by the Quality Assurance Agency upon approval by the department.
   4. (4) The name, address and telephone number of the Quality Assurance Agency employing or to employ the applicant.
   5. (5) An attached resume detailing the education, training and experience of the applicant which demonstrates how he or she meets the requirements of Section 4856.
   6. (6) The typed or printed name and signature of the applicant on form HCD-MH 471, Absence of Conflict of Interest Statement, dated May 1989 and provided by the department, certifying under penalty of perjury to the absence of any conflict of interest, potential for a conflict of interest or any collusive or fraudulent practices as specified in Section 4872. The applicant shall also include the date, county and state that certification was executed.
   7. (7) The typed or printed name and signature of the applicant certifying under penalty of perjury to the accuracy of the information provided.
   8. (8) The date, county and state that certification was executed.
2. (b) Form HCD-MH 471 Absence of Conflict of Interest Statement, dated May 1989 shall be attached to form HCD-MH 469 Application for Quality Assurance Inspector Approval dated May 1989.
3. (c) The application shall be accompanied by the fee specified in Section 4884(c) for an Application for Quality Assurance Inspector Approval.
4. (d) The applicant shall present documentation necessary to determine the applicant's eligibility to receive public benefits pursuant to chapter 5.5 of this division, beginning with section 5802.

Note: Authority cited: Section 18020, Health and Safety Code. Reference: 8 U.S.C. Sections 1621, 1641 and 1642; and Sections 18013.2, 18020 and 18031, Health and Safety Code.

History

1. New section filed 10-6-88 as an emergency; operative 10-6-88 (Register 88, No. 42). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 2-3-89.

2. The Certificate of Compliance transmitted to OAL 1-31-89 was disapproved. Order of Repeal of 10-6-88 emergency order filed 3-2-89 by OAL pursuant to Government Code Section 11349.6 (Register 89, No. 11).

3. New section filed 3-3-89 as an emergency; operative 3-3-89 (Register 89, No. 11). A Certificate of Compliance must be transmitted to OAL within 120 days, by 7-3-89, or emergency language will be repealed.

4. Certificate of Compliance including amendment transmitted to OAL 6-29-89 and filed 7-24-89 (Register 89, No. 32).

5. New subsection (d) and amendment of Note filed 3-20-98 as an emergency; operative 4-6-98 (Register 98, No. 12). A Certificate of Compliance must be transmitted to OAL by 8-4-98 or emergency language will be repealed by operation of law on the following day.

6. New subsection (d) and amendment of Note refiled 8-4-98 as an emergency; operative 8-4-98 (Register 98, No. 32). A Certificate of Compliance must be transmitted to OAL by 12-2-98 or emergency language will be repealed by operation of law on the following day.

7. Certificate of Compliance as to 8-4-98 order, including amendment of subsection (d), transmitted to OAL 12-1-98 and filed 1-14-99 (Register 99, No. 3).