Home Health Agency 
Initial 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).

Legislation updates:

• Please review AFL-26​-28. This AFL notifies HHAs of the chaptering of Senate Bill (SB) 164 (Chapter 27, Statutes of 20​​26) establishing a moratorium on HHA licensure, prohibiting the California Department of Public Health (CDPH) from issuing a new HHA license or approving the addition of a branch office to an existing license as of June 29, 2026. Applications for initial licensure, addition of a branch office, a change of geographical service area, or a change of location outside of a HHA's approved geographical service area are subject to the moratorium.

• Application after June 29, 2026 – Individuals or entities interested in applying for HHA licensure after June 29, 2026, should begin by submitting an exception request. This consists of submitting a written justification and supporting documentation to demonstrate need based on geographic concentration to CAB. If CAB determines there is a need based on geographic concentration, CAB will notify the applicant that they may submit an application. 

• Health and Safety Code (HSC) section 1728.1 requires an HHA to have an administrator, administrator designee, director of patient care services (DPCS), and director of patient care services designee (DPCSD). Each management personnel must submit an Applicant Individual Information - HS 215A form, a resume, and a list of HHA that the individual is currently serving as management personnel. CDPH must use this information to verify professional licensure status of these individuals and may verify their association with the HHA agency and/or their work history. Verification may include contacting HHA agency personnel or previous employers.
  

• The HHA shall notify CDPH of any change in the administrator, administrator designee, DPCS, or DPCSD by submitting the information described above within 10 business days of the change.
  

• Existing HHAs must submit their change of administrator, administrator designee, DPCS, and DPCSD applications no later than March 31, 2027.
  

• SB 164 requires an applicant for licensure of a private HHA to submit fingerprints to the California Department of Justice, for the purpose of furnishing the person's criminal record to CDPH, for any person with a 5 percent or greater interest in a corporation, partnership, or association that owns the HHA.​​
  

How to Apply

An applicant must submit a completed application packet to the Centralized Applications Branch (CAB). The provider instructions are a resource to guide you through the process. The provider checklist identifies the required forms and supporting documents needed to apply for licensing and certification. 

Please refer to the following links to get started:

• Provider Instructions
  
• Provider Checklist ​
  

Application Packet Forms

• ​HS 200 - Licensure and Certification Application (PDF, 1.5MB​)
  
• HS 215A - Applicant Individual Information (PDF)​
• ​​HS 309 - Administrative Organization and Organizational Structure (PDF)
• CDPH 322 - Transmittal Application for Criminal Record Clearance (PDF) 
  
• CDPH 325 - Criminal Record Clearance Submissions (PDF)
  
• BCIA 8016 - Request for Live Scan (PDF, 1.3MB) ​
  
• HS 328 - Notice of Effective Date of Provider Agreement ​(PDF)
  
• DHCS 9098 - ​​​Medi-cal Provider Agreement (PDF)
  
• CMS 671 - Long Term Care Facility Application for Medicare & Medicaid (PDF)
  
• CMS 1561 - Health Insurance Benefits Agreement (PDF)
  
• CMS 1572 - Home Health Agency Survey and Deficiency Report​ (PDF)
  
• CMS 855A - Medicare General Enrollment Health Care Provider/Supplier Application​ (PDF)
  
• HHS 690 - Assurance of Compliance (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 Division
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377​