Home Health Agency 
Change of Governing Board Application Packet

A State license is required to operate as a Home Health Agency (HHA) in California. An HHA means "a private or public organization, including but not limited to, any partnership, corporation, political subdivision of the state, or other government agency within the state, which provides, or arranges for the provision of, skilled nursing services, to persons in their temporary or permanent place of residence", pursuant to Title 22 of the California Code of Regulations (CCR) section 74600(a).

To report a Change of Governing Board, you must complete the required application packet. Refer to Title 22 CCR sections 74661, 74667, and 74717 for information regarding licensure requirements.

How to Apply

An applicant must submit a completed application packet to the Centralized Applications Branch (CAB). The application packet contains the required forms in one location. The provider checklist identifies the required forms and supporting documents needed to apply for licensing and certification. The provider instructions are a resource to guide you through the process. The Sample Application Packet is a visual aid that displays a sample of the completed forms contained in the application packet.

Please refer to the following links to get started:

• Provider Instructions (PDF)
• Provider Checklist 
  

Application Packet Forms​

• HS 200 – Licensure and ​​Certification Application (PDF, 1.5MB)
• HS 2​​15A – Applicant Individual Information (PDF)
• HS 309 – Administrative Organization (PDF)​​​
  

Where to Submit Applications

Submit completed application packets to the CAB at the address listed below. Do not send any completed application packets, forms, or supporting documents to the local CDPH, District Office.

          California Department of Public Health
          Licensing and Certification Program
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377