Service Provider Forms
All Service Providers
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Become A Service Provider - Contact the appropriate Resource Coordinator to apply to become an SDRC Service Provider.
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Vendor Disclosure Statement (DS1891) - Review the Department of Developmental Services information about the DS1891 form requirement.
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Breach Incident Report (DS5340B) - Review the Department of Developmental Services Breach Incident Reporting process. Vendor breaches also need to be reported to the U.S. Department of Health and Human Services (HHS) Office of Civil Rights (OCR) online here.
Nursing Level Respite Providers
Residential Service Providers
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Looking at Service Quality – Providers handbook required to be kept in all vendored Community Care licensed homes
Vendor Applications
Become a Service Provider
If you are interested in becoming a provider for the California regional centers you must complete an application and complete a process referred to as “vendorization”. Service providers are vendored by the regional center in whose region (known as catchment area) the service is located, and that regional center is known as the “vendoring regional center.” The vendoring regional center is responsible for ensuring that the applicant meets the licensing and Title 17 requirements for vendorization, determining the appropriate vendor category for the service, and authorizing or not authorizing vendorization based upon review of the documentation submitted by the applicant.
The vendorization process is for identification, selection, and utilization of service providers based on their qualifications and other requirements. This process allows regional centers to verify, prior to the provision of services to clients, that the applicant meets all the requirements and standards specified in the regulations. Applicants who meet the specified requirements and standards are assigned a service code and a unique vendor identification number. Although a regional center must vendor an applicant who meets all the requirements for the service to be provided, vendorization in no way obligates a regional center to make referrals to or purchase services from that vendor.
Prospective service providers should contact the San Diego Regional Center (SDRC) Community Services Department prior to filing an application to discuss the proposed service and process. (See below for contact information). Once the application is submitted with the required forms, licenses and certificates, SDRC has 45 days from receipt of the application to determine whether the applicant meets the requirements of Title 17.
Become a Service Provider Today!
Please review the DDS Guidelines for Vendorization and Rates Frequently Asked Questions.
For information regarding services, becoming a provider and/or a vendor application, please contact the appropriate Resource Coordinator.
SDRC Community Services
For information regarding services, becoming a provider and/or a vendor application, please contact the appropriate Resource Coordinator
Miguel Larios
Community Services Director
Robert Webb
Resource Manager
Erik Peterson
Resource Development Manager
Resource Coordinator
Supported Living (SLS)
Independent Living (ILS)
Coordinated Family Supports (CFS)
Personal Assistance (PA)
Resource Coordinator
Self Determination
FMS
Participant Directed Services
Translation/Interpretation
Conferences/Trainings
Todd Lordson
Transportation Coordinator
Transportation Services
Jorge Malone
Transportation Assistant
Transportation Services
Juan Gonzalez
Health & Safety Waiver Specialist
Vacant
HCBS Specialist
Tiffany Swan
Emergency Management Coordinator
Kristen Van Den Broek
Quality Assurance
Sarah Pierce
Quality Assurance
Albert Noriega
Rate Specialist
Breach Incident Report
If information about an individual a vendor serves is ever lost, stolen or received by anyone who is not that person or that persons legally authorize representative, the California Department of Developmental Services (DDS) considers that a “security breach.” Anytime there is a security breach of information possessed by a vendor, DDS requires the vendor to both notify the person whose information was breached (or their legally authorized representative) by letter, as well as the Regional Center using form DS 5340B. The letter sent to the individual needs to be sent within 60 days of the discovery of the breach and a copy needs to be sent to the Regional Center. Vendor breaches also need to be reported to the U.S. Department of Health and Human Services (HHS) Office of Civil Rights (OCR) online here.
If you have any questions, please contact Seth Mader, San Diego Regional Center’s Information Security Officer.
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Template – Notification Letter – Word Document
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Breach Report Form – Secure Electronic Signature