Cover Letter

Letter on company letterhead with the following information:

• For Initial, if Licensee owns other existing ADHC centers, provide license numbers of those centers
• For CHOW, provide license number of current center
• Facility name and address
  
• Facility ID number (if known)
• Brief description of request
• Previous and proposed/new location
• 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/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 
  

[Health and Safety Code (HSC) section 1575.1 and 1575.2] [Title 22 California Code of Regulations (CCR) section 78205]

Tips

• Page 2, section A, Item 7 – The question refers to "bed capacity", however this number will represent "participants" for ADHC

• Page 6, section B, Item 6 —This parent company will have its own Employer Identification Number (EIN)
  

Submit one of the following IRS tax documents showing entity's legal name and Tax Identification Number:

• Letter 147-C (EIN Confirmation Notification)
• Form 941- (Employer's Quarterly Federal Tax Return)
• Form 8109-C (Federal Tax Deposit Address Change)
• Form SS-4 (Confirmation Notification)
  

D.1 - Control of Property [22 CCR section 78205(a)(8)]

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 1575.1(a)(1) and (2)]
[22 CCR section 78205(a)(2) and (a)(6)]

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

• Administrator of the facility and the Program Director
• 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 exceeding 5 percent or more in the applicant organization and/or parent organization

Tips

• Page 2, section B, Item 3 — 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, must complete section H for the Facility Information Sheet

Administrative Organization

Along with the HS 309, the following supporting documents according to organizational type must be submitted.

Limited Liability Company (LLC)

• Filing Statement from the Secretary of State
• Articles of Organization
• Operating Agreement
• List of Managing Members (only if additional space is needed to input all managing members)
  

Public Agency

[HSC section 1575]

[22 CCR section 78401(e)]

Copy of signed Resolution

Transmittal Application for Criminal Background Investigation

[HSC section 1575.7(a)(1)(2)]

Complete form for the following individuals and mail to the address indicated on the form:

• Administrator, Program Director, and Fiscal Officer
  

Transfer Agreement

[22 CCR section 78205 (a)(12)]

Copy of current written transfer agreement with a general acute care hospital, a physician, and an ambulance service.

• May submit a CDPH 5000 Program Flex if Transfer Agreement cannot be obtained.

Tips

• The facility administrator may sign this form
  

The facility may not have a provider number yet and this line may be left blank

Civil Rights Compliance Review

Send directly to Office of Civil Rights – address is on last page of the form

Proposal to Share Space

[HSC section 1578 and 1578.1]

If your facility will share space according to HSC section 1578 and 157.1, submit a copy of this form.

Note: Aside from sharing space with ADP, if proposing to share space with any other organization, must obtain prior approval from local District Office before submitting an application to CAB.

Balance Sheet

[22 CCR section 78205]

• The balance sheet should list all assets, liabilities, and equities of the legal entity submitting an application as certified by the entity's independent public or certified public account. It must be current within 90 days of the date of application. If that is not available, an unaudited balance sheet is to be submitted for the last calendar quarter preceding the date of application
  

If available, also submit the most recent certified public accountant audited financial statements of the applicant. Monetary and non-monetary donations (e.g., equipment, staff time) to the center from any source would be considered "Other Current Assets" of the Licensee

Operating Budget

[22 CCR section 78205(a)(7)]

The operating budget should indicate the center's projected total revenues and expenditures for the total year and for an average month

Fire Safety Inspection Request (not applicable for a CHOW unless there is construction)

[HSC section 1574.7(b)]

[22 CCR section 78409]

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