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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​​​​

​Chronic Dialysis Clinic and End-Stage Renal Disease Clinic 

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)
  • Medicare
  • Medi-Cal

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:
  • ​License number (only applicable for CHOW)
  • Facility name and address
  • Facility ID number (if known)
  • Brief description of request
  • 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​
HS 200 (PDF)

Licensure & Certification Application 

[Health and Safety Code (HSC) section 1212(a), 1225(c)(1)]

Tip

  • ​Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions

​Supporting Documents

A.10 – California Department of Health Care Access and Information (HCAI) [California Building Code section 1226 and HSC section 1226] And/ Or Certificate of Occupancy

HCAI and Local Building Authority

One of the two documents are required:

  • Written certification: The local building authority or HCAI must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements: 
    • California Building Code (CBC)
    • California Fire Code (CFC)
    • California Electrical Code (CEC)
    • California Mechanical Code (CMC)
    • California Plumbing Code (CPC)
    • California Administrative Code (CAC)
       
  • CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, to certify the facility conforms to current applicable Title 24 (OSPHD 3 Standards). This form must be signed by the local building authority or HCAI

Note: Title 24 compliance does not apply to CHOWS unless there has been construction and/or remodeling.

If construction occurred and if the construction resulted in a new building or addition:

  • Submit a Certificate of Occupancy
  • This is not applicable if there were alterations or repairs to existing buildings performed or conversion of space

​Supporting Documents

B.3 – Internal Revenue Service Documentation

[HSC section 1212(a)]

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

  • Form 941- (Employer’s Quarterly Federal Tax Return)
  • Form 8109- C (FTD Address Change)
  • Letter 147-C (EIN Confirmation Notification)
  • Form SS-4 (Confirmation Notification)
Supporting Documents 

B.3 Organizational Chart – Owner Type

[HSC section 1212(a)] [42 CFR section 494.180]

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
  • Parent company of applicant, if applicable, and all of the licensed agencies/facilities it is operating - see B.6
​Supporting Documents 
B.3 Non-Profit Status – Owner Type

[HSC section 1212 (a)]

Submit a copy of the IRS Tax Exempt Determination Letter showing the non-profit 501(c) (3) status, if applicable

​Supporting Documents 
B.4.b License Revocation (if applicable)

[HSC section 1212 (a)]

Submit additional information, including all ownership and facility information, date and any final action

​Supporting Documents 
B.6 Organizational Chart

[HSC section 1225 (a)] [42 CFR 494.180]

If licensee is a subsidiary of another organization, include an organizational chart

Supporting Documents
D.1 Control of Property (only required for new property)
[HSC 1212(a)]

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

Floor Plan

[HSC section 1212(a)(9)]

Submit a floor plan that coincides with your office space​

HS 215A (PDF)​

Applicant Individual Information 

[HSC section 1212 (a), 1212(a)(6)] [Title 42 California Code of Federal Regulation (CFR) sections 420.206(a)(3), 455.104, 494.140 subdivisions (a) and (b)(1), 494.180 subdivisions (a), (b) and (j)]

This form must be completed for the following individuals:

  •  Administrator of the facility, Medical Director and the Director of Nursing
  • Owners, directors, board members, corporate officers, LLC members/managers, and partners of the parent, grandparent, great grandparent, and etc. organization, if applicable
  • Each individual having a beneficial interest of exceeding five percent or more in the applicant organization and/or parent, grandparent, great grandparent, and etc. organization
Tips
  • Page 2, section B — 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, complete Section H: Facility Information Sheet

Supporting Documents​

Facility Information Sheet

Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency:

  • Facility name
  • Facility address
  • Type of facility
  • Type of business entity (include EIN Number)
  • Individual’s nature of involvement
  • Individual’s dates of involvement
​Supporting Documents 
Resume

[42 CFR 494.140 (a)(1), 494.140 (b)(1)(iii)]

A resume is only required for the Administrator(s), Director of Nursing, and Medical Director

​Supporting Documents
Professional Licenses/ Certificates

[HSC sections 1212(a)] [42 CFR 494.140 subdivisions (a) and (b)]

  • An active registered medical license is required for the Medical Director and Director of Nursing
  • Provide a printout of the current license from the Department of Consumer Affairs (https://sea​rch.dca.ca.gov/) 

HS 309 1st Page​ (PDF)


Administrative Organization

[HSC section 1212 (a)] [42 CFR 494.180]

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

Supporting Documents​

Corporation

[HSC section 1212(a)]

  • Filing Statement from CA Secretary of State (only if Articles of Incorporation are not endorsed by the CA Secretary of State)
  • Articles of Incorporation (Endorsed by CA Secretary of State)
  • By-Laws (Stating the size of boards)
  • 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 located in the top right corner of the applicant Articles of Incorporation

Supporting Documents​


Limited Liability Company (LLC)

[HSC section 1212(a)]

  • 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 

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

​Supporting Documents

Partnership

[HSC section 1212(a)]

Copy of signed Partnership Agreement

​Supporting Documents
Out of State Corporations

[HSC 1212 (a)]

Copy of the Certificate of Qualification from the CA Secretary of State allowing the applicant to do business in California

HS 602​ (PDF)



Transfer Agreement

[42 CFR 494.180(g)(3)]

Copy of current (within one year of submission of application) written transfer agreement with hospital appropriate to meet medical emergencies

STD 850 (PDF)

Fire Safety Inspection Request

[42 CFR 494.60 (d)(3)]

The STD 850 form is required. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form.

  • This form is not required for a CHOW unless there has been construction and/or remodeling.
  • 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 HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form.
  • If the STD 850 form is NOT required for a particular MOBILE clinic, a written statement from the local fire agency must be submitted.


​​Required Documents for a CHOW Only​

Forms and Supporting Documents​​​

Additional Instructions

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

Supporting Docum​ents

In addition to the forms required for an Initial application listed above submit the documents requested below: [HSC section 1212(a)]​

  • Copy of Purchase Agreement or Operating Transfer Agreement
  • A letter from the prospective licensee (to CDPH) stating the location where the stored patient medical records will be maintained and affirming the records will be made available to the previous licensee [SQHC, 2003, section 6.3(b)(3)(g)]
  • Copy of “Interim Management Agreement” (if applicable)


​​Medi-Cal Certification Documents 

Forms and Supporting Documents​​​

Additional Instructions

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

DHCS 9098 (PDF)  

Medi-Cal Provider Agreement

  • Do not leave any questions blank. Enter “same” or “N/A” if not applicable
  • The mailing address must be the same as reported on the HS 200 form, section C, Page 8, item 3.c.1
  • Notarized signature page is required
  • Submit the “Acknowledgement”​​ page from the notary public, if applicable
HS 328 (PDF) ​

Notice – Effective Date of Provider Agreement​

If applying for both Medi-Cal & Medicare certification, only submit one copy of this form


Medicare Certification Documents 

Forms and Supporting Documents​​​

Additional Instructions

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

Business Plan Letter

Business Plan Letter

Letter explaining in detail the Business Plan for operation of the ESRD, including a description of all services to be provided

CMS 855B (PDF)

Medicare General Enrollment Health Care Provider/ Supplier Application​

  • This application is from the U.S. Department of Health and Human Services
  • The completed application should be mailed directly to the appropriate fiscal intermediary
​​CMS 3427​ (PDF) 

End Renal Disease Application/ Notification and Survey and Certification Report

[State Operation Manual 2274B]

Items 1-34 must be completed with applicable information. The surveyor will bring a copy of the form to update and add information when the certification survey is conducted

​Life Safety Code

Life Safety Code Attestation for Exempt ESRD Facilities

[42 CFR section 494.60 (d)]

  • ​Life Safety Code exemption attestation for ESRD
  • Signed by the facility Administrator​


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