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

​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
  

​B.3 – Organizational Chart – Owner Type

[HSC section 1212(a)] [Title 42 California Code of Regulations (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 ID/EIN # 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
  

[HSC section 1212(a)]

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

[HSC 1212(a)]

Submit a signed 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 1212(a), 1212(a)(6)] [42 CFR sections 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, the Director of Nursing and the Medical Director
• 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

• 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
  

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

Administrative Organization

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

Along with the HS 309, depending on organizational type, the following supporting documents must be submitted:

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)
  

Partnership

[HSC section 1212(a)]​

Copy of signed Partnership Agreement

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.