Adult Day Health Center
Report of Change Application Checklist for Change of Name
The following is a list of application forms and supporting documents required for a complete application packet. Failure to include each of the forms and documents will delay processing.
Checklist and Instructions - Pālease submit your documents in this order
Required Documents for a Change of Name
Forms andāāā Supporting Documentsāā
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āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
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āCover Letter
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Cover Letter
Letter on company letterhead with the following information:
- License number
- Facility name and address
- Indicate if the change of the name is for the Licensee and/or the Facility
- Facility ID number (if known)
- Brief description of request
- Previous and āproposed/new name
- 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)
- āāSignatureā
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āHS 200 (PDF, 1.5MBā)
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Licensure & Certification Application
[Health and Safety Code (HSC) section 1575.2]
[Title 22 California Code of Regulations (CCR) section 78205]
Tips
- Page 6, section B, Item 6 āThis parent company will have its own Federal tax ID number
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āSupporting Documents
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Board Resolution
[22 CCR section 78205(a)(17)]
Submit a copy of board resolution signed by officers and directors authorizing the facility name change and with the effective date.
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āSupporting Documents
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Articles of Incorporation
[22 CCR section 78205(a)(3)]
If the Licensee name or Corporate name changes, submit a copy of amended Articles of Incorporation filed with the CA Secretary of State
Note: In case of entity conversion, submit a copy of
conversion document (PDF) filed with the CA Secretaryā of State
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