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HEALTH CARE FACILITY LICENSING AND CERTIFICATION

 Contact Us

Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

For application status requests, please include the following in your email:

  • Application ID (if applicable)
  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Number

​Adult Day Health Center 

Initial and Change of Ownership Application Checklist 

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.

  • Initial License         
  • Change of Ownership (CHOW)                                       
  • Community-Based Adult Services (CBAS)                             
  • Program of All-Inclusive Care for the Elderly (PACE)​

Checklist and Instructions - P​lease submit your documents in this order

Required Documents for an Initial License or CHOW 

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​: ​

  • 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 ​
​Pre-Screened Approval Letter
Pre-Screened Approval Letter
  • Required for Community-Based Adult Services (CBAS) Programs Only
  • This letter is issued by the California Department of Aging and only required for CBAS participants
  • Not required for Program of All-inclusive Care for the Elderly (PACE) Organizations
HS 200 (PDF)
Licensure & Certification Application 

[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)
​Supporting Documents
A.10 - Construction

[HSC section 1575.2]

[22 CCR section 78501(a)(1) and (b)]

For Initial, submit one of the following regardless if construction occurred or not:

  • Evidence of compliance with local building code requirements or;
  • Certificate of Occupancy issued by the local building authority

​Supporting Documents

B.2 - IRS Internal Revenue Service Documentation

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)​

​Supporting Documents

B.3 - Organizational Chart - Owner Type

[22 CCR section 78205(a)(4)]

Submit an 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 of these individuals

  • 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

​Supporting Documents

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 ​

Supporting Documents

E. - Management Company Agreement

(If applicable) [HSC 1575.1(a)(3)(A)]

 [22 CCR section 78205(a)(11)] ​

Facilities operated under a Management Agreement between the licensee and a management company must complete and submit Attachment E-1 (Management Company Information) on HS 200 along with a copy of the Management Agreement. The Management Agreement must state that the licensee is responsible for the facility.

HS 215A (PDF)​

Applicant Individual Information 

[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​

Supporting Documents​

Resume

[22 CCR section 78205(2)]

A resume and proof of education is required for the Administrator and Program Director​

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
  • 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
  • List of Managing Members (only if additional space is needed to input all managing members)

HS 309 2nd Page​ (PDF)


Organizational Structure 

[22 CCR section 78205(4)]

Only complete fields that are applicable to applicant's entity type

Tip​

  • Page 2, item 1 — Health care districts will fill in the circle for other​
​Supporting Documents

Public Agency

[HSC section 1575]

[22 CCR section 78401(e)]

Copy of signed Resolution

​Supporting Documents

Partnership

[HSC section 1575.1(a)(1)]

Copy of signed Partnership Agreement


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

CDPH 325 (PDF)


Criminal Record Clearance Submissions

[HSC section 1575.7]

Submit with the following individuals' names listed on the form:

  • Administrator, Program Director, and Fiscal Officer 

HS 602​ (PDF)


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​

CDPH 609 (PDF)​


Bed or Service Request

[HSC section 1578.1]

[22 CCR section 78221 and 78347]

  • For new facilities or initial licensure, complete the columns marked "Requested Beds" and "Requested Services"
  • For currently licensed facilities or Change of Ownership complete the columns marked "Existing Beds" and "Existing Services" and the columns marked "Requested Beds" and "Requested Services"
  • For CHOW applications, the information marked in the "Existing" and "Requested" fields must be the same

Tips

  • Approved Capacity – do not worry about filing out this section. This section is for CAB use only
  • If you wish to remove a service from your license, the best way to indicate this is to list the request in the other section on this form

DHCS 1051​ (PDF)


Civil Rights Compliance Review

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

CDA ADH 0006 (PDF)​


Staffing/Services Arrangement 

[22 CCR section 78205]

Form must be signed by Administrator or Program Director

CDA ADH 0007 (PDF)


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.

CDPH 5000 (PDF)


Program Flexibility Request

[22 CCR section 78217]​

If applicable, this form can be submitted if a Transfer Agreement cannot be obtained.

Note: However, for all other program flex requests the program flex must be submitted online via the Risk & Safely Solutions (RSS) platform.

Note: Facility must be currently licensed in order to access the RSS portal, therefore program flexes for Initial applications will not be accepted. 

CDA IMS 33 (PDF)

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

CDA IMS 35 (PDF)


Cash Flow Forecast

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

  • The cash flow forecast should project on a monthly basis the center's actual cash revenues and expenditures for one year starting from the first month of service provision. It should accurately reflect when and how much money would be received and spent. This is cash only – do not include non- monetary donations or in-kind service donations. Use the CDA IMS 37 form (below) for the breakdown of the expenditure cost centers categories before proceeding with the Cash Flow Forecast​
  • The written assumptions supporting revenues and expenditures cash flow projections should include the following:
    1. Projected number of private pay participants,
    2. Projected number of assessment and regular days of attendance,
    3. Regular days of attendance for each month and combined positions, and
    4. Projection of growth each month
  • Fee schedule for participants​

CDA IMS 37 (PDF)


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

Map and Floor Plans​

Map and Floor Plans

[22 CCR section 78205(a)(8), section 78501, 78503, and 78505]

  • Submit a map identifying the ADHC service area
  • The physical plant accommodations, general building requirements and space requirements
    • Submit a detailed and legible floor plan of the "existing" or "proposed" ADHC indicating square footage of each of the areas to be used and noting where basic services will be provided so it can be determined if these requirements have been met. The floor plan should indicate:
      1. Office space
      2. Bathrooms (e.g., number of toilets in each bathroom), and
      3. Entrances and emergency exits, and outdoor areas

STD 850​​ (PDF)​


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


​​Required Documents for a CHOW Only​

Forms and Supporting Documents​​​

Additional Instructions

(Each form listed also has instructions on the form) ​

Supporting Documents

All of the forms required for an “Initial" application listed above in addition to the documents requested below:​

[HSC section 1575.1(a)(1) and (b)]

[22 CC​​R section 78225(a), 78227, and 78435]

  • Copy of "Purchase Agreement" or "Operating Transfer Agreement"

A letter from the prospective licensee (to CDPH) stating where the stored patient medical records will be maintained, and that the records will be made available to the previous licensee [22 CCR section 78435]​





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