HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Adult Day Health Center

Report of Change Application Checklist for Change of Governing Board

The following is a list of forms and supporting documents required for a complete application packet. Failure to include every form or document will delay processing or lead to denial.

Checklist and Instructions - Please submit your documents in this order and save a copy of all submitted documents for your records.

Required Documents for a Change of Governing Board

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
Cover Letter	Cover Letter Letter on company letterhead with the following information: License number Facility name and address Facility ID number (if known) Brief description of request Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address) The Department will use the invoice contact email address to invoice the application fee The Department will use the applicant contact email address to send all application correspondence General Contact Information (name, title, phone number, fax, email address, and alternative contact information) The Department will use this information to contact the facility for day-to-day business Emergency Contact Information (name, phone number, fax, email address, alternate email, 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/cahan) All Facility Letter Contact Information (name, phone number, fax, and email address) The Department will use this information to send All Facility Letters Facility Contact (Public Use) Information (phone number, fax, email address, and website address) The Department will use this information to store facility contact information for the public Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents Signature
HS 200 (PDF, 1.5MB)	Licensure & Certification Application [Health and Safety Code (HSC) section 1575.2(d) and 1575.1] [Title 22 California Code of Regulations (CCR) section 78401(c)(4)] Tips: Page 6, section B, item 6 — An organization will have its own Federal tax ID number Signature must be from the applicant (Licensee/owner), not the Administrator, unless the owner is the Administrator
Supporting Documents	B.3 - Organizational Chart - Owner Type [22 CCR section 78205(a)(4)] Submit a before and after organizational chart if the owner is a for-profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following: Applicant’s owners, including ownership percentages, Tax IDs/EINs and all directors, board members, corporate officers, LLC members/managers, and/or partners Note: Submit the HS 215A form for each new individual Management company of applicant, if applicable, and all of their facilities Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating – see B.6
HS 215A (PDF)	Applicant Individual Information [HSC section 1575.1] [22 CCR section 78205(d)(6) and 78401(c)(4)] This form must be completed and signed for the following individuals: New directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization 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 and attach the facility information sheet
HS 215A Page 3 (PDF)	Facility Information Sheet [22 CCR section 78205(a)(6)] Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency: Facility name Facility address Type of facility Type of business entity (include EIN Number) Individual’s nature of involvement Individual’s dates of involvement
HS 309 1st Page (PDF)	Administrative Organization Along with the HS 309, the following supporting documents according to organizational type must be submitted.
Supporting Documents	Corporation [22 CCR section 78205(a)(3)] Filing Statement from the Secretary of State Articles of Incorporation By-Laws Foreign (out-of-state) applicants submit a copy Certificate of Qualification from the California Secretary of State List of Board of Directors (only if additional space is needed to input all board of directors) Tip Page 1, item 3 — The incorporation date is located in the top right corner of the applicant Articles of Incorporation
Supporting Documents	Limited Liability Company (LLC) Filing Statement from the Secretary of State Articles of Organization Operating Agreement Foreign (out-of-state) applicants submit a copy Certificate of Qualification from the California Secretary of State List of Managing Members (only if additional space is needed to input all managing members) Tip Page 1, item 3 — The organization date is located in the top right corner of the applicant Articles of Organization
Supporting Documents	New Board Member Verification Documentation verifying the appointment of new Board Member(s), such as copy of board meeting minutes, appointment letter, resolution etc.
HS 309 2nd Page (PDF)	Organizational Structure [22 CCR section 78205(a)(4)] Only complete fields that are applicable to applicant’s entity type.
Supporting Documents	Public Agency [HSC section 1575] [22 CCR section 78401(e)] Copy of signed Resolution
Supporting Documents	Partnership Copy of signed Partnership Agreement
CDPH 325 (PDF)	Criminal Record Clearance Submissions [HSC section 1575.7] Submit this form only for the new Fiscal Officer
CDPH 322 (PDF)	Transmittal Application for Criminal Background Investigation [HSC sections 1575.7(a)(1) and 1575.7(a)(2)] Mail this form to the address indicated on the form only for the new Fiscal Officer Submit this form to CDPH Criminal Background Section (address is listed on the form).
BCIA 8016 (PDF)	Request for Live Scan [HSC section 1575.7] Mail this form to the address indicated on the form only for the new Fiscal Officer Note: In addition, submit copy of this form to CDPH Criminal Background Section. Centralized Applications Branch may also request a copy of this form.

Note: Save a copy of all submitted documents for your records.

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