Cover Letter

Letter on company letterhead with the following information:

• License number (only applicable for CHOW)
• Facility name and address
• Facility ID number (if known)
• Brief description of request
• Attestation that the applicant provider is located in proximity, in time and distance, to a facility with the capacity for management of obstetrical and neonatal emergencies, including the ability to provide cesarean section delivery, within 30 minutes from time of diagnosis of the emergency. Include the facility name and address with the capacity for management of obstetrical and neonatal emergencies [Health and Safety Code (HSC) section 1204.3(4)(A)]
• Contact Information (name, title, phone number, and e- mail address)
• Emergency Contact Information (name, email, alternate email, phone, fax, and phone number that will receive text messages). The Department will use this information to contact the provider in the event of an emergency using the California Health Alert Network (CAHAN). All information provided must allow CAHAN to contact the provider on a 24/7/365 basis for distribution of health alerts. For additional information: CAHAN (https://www.calhospitalprepare.org/post/california-health-alert-network-cahan)
  
• Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address)
• Signature​

A.10 – California Department of Health Care Access and Information (HCAI) [California Building Code section 1226 and Health and Safety Code (HSC) section 1226] And/ Or Certificate of Occupancy

One of the two documents are required:

• California Building Code (CBC)
• California Fire Code (CFC)
• California Electrical Code (CEC)
• California Mechanical Code (CMC)
• California Plumbing Code (CPC)
• California Administrative Code (CAC)
  

• ​​​​​CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by the local building authority
  

• Submit a Certificate of Occupancy
  
• This is not applicable if there were alterations or repairs to existing buildings performed or conversion of space​
  

​B.3 - Organizational Chart 

[HSC section 1212(a)]​

Submit an organization chart/flow chart if the owner is a profit or nonprofit corporation, limited liability company (LLC), or general partnership. The organization chart needs to display the following:

• Applicant’s owners, directors, board members, corporate officers, LLC members/managers, and partners.
  Note: Submit the HS 215A form for each of these individuals
• Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating – see B.6
  

Note: If CHOW, enter current facility name

[HSC section 1212(a)]

Submit the HS 215A form for the administrator of the facility

[HSC section 1212(a)]

Submit a copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed Licensee

[HSC Section 1212(a)]

This form must be completed and signed for the following individuals:

• Administrator of the facility
• Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization and/or management company
• Each individual having a beneficial interest of 5% or more in the applicant organization and/or parent organization [HSC Section 1212(a)]
• Signature is required 
  

Tips

• Page 2, section B — The date of birth is an identifier, as several people may have the same name. This will ensure that each individual is associated with the correct facility or entity
• Page 5, section E — Submit ten years of employment history, indicating the start and end dates of employment, job title, employer name and address. The applicant may submit a resume in lieu of completing section E; however, the resume must contain all required information requested in section E
• Page 7, section F — If answering yes to any question in this section, complete Section H: Facility Information Sheet
  

Resume

[HSC section 1212(a)]

A resume is required for the Administrator

• Filing Statement from the Secretary of State (only required if Articles of Incorporation are not endorsed by the CA Secretary of State)
• Articles of Incorporation (endorsed by CA Secretary of State)
• By-Laws (stating the size of board)
• List of Board of Directors (only if additional space is needed to input all board of directors) 

• Page 1, item 2 — The Administrator of Corporation LLC is usually the CEO/President
• Page 1, item 3 — The incorporation date is located in the top right corner of the applicant Articles of Incorporation
  

• Enter the number of members/managers
• Submit the HS 215A form for each individual listed under this item

Public Agency

Submit a copy of signed Resolution

Fire Safety Inspection Request

[HSC section 1212(a)]

The STD 850 form must be submitted or a similar form from the local fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form

Note: This form is not required for a CHOW unless there has been construction and/or remodeling. ​

• Do not leave any questions blank. Enter “same” or “N/A” if not applicable
• The mailing address must be the same as reported on the HS 200 form, section C, Page 8, item 3.c.1
• Notarized signature page is required
• Submit the “Acknowledgement” page from the notary public