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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​


​Congregate Living Health Facility

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)                                       

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
  • 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
HS 200 (PDF)

Licensure & Certification Application

[Health and Safety Code (HSC) section 1267.13(n)] [Title 22 California Code of Regulations (CCR) section 72201]

Tips

  • Page 6, section B, item 6 —This parent company will have its own Employer Identification Number (EIN)
  • Page 10, section C, Item 9 - Select which of the following services will be provided:
    • CLHF A: Services for individuals, who are mentally alert, physically disabled individuals who may be ventilator dependent
    • CLHF B: Services for individuals who have a diagnosis of terminal illness, a diagnosis of a life-threatening illness; or both
    • CLHF C: Services for individuals who are catastrophically and severely disabled. Services offered to a catastrophically disabled person shall include, but not be limited to speech, physical, and occupational therapy
​Supporting Documents

A.7 - Bed Capacity

[HSC sections 1250(i) and 1267.16(c)]

For a CLHF with more than six beds for persons who are terminally ill and for persons who are catastrophically and severely disabled:​

  • Submit a Conditional Use Permit
  • The Conditional Use Permit must meet the requirements of the City or County in which it is located unless those requirements are waived by the City or County
​​Supporting Documents

A.10 - Construction

[HSC section 1267.19]

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
[HSC section 1267.13(n)] [22 CCR section 72201]

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

[HSC section 1267.13(n)] [22 CCR section 72201]​

Submit an organizational chart if the owner is a 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 they are operating- see B.6

​Supporting Documents

D.1 - Control of Property

[HSC section 1267.13(n)] [22 CCR section 72201]

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 

​​HS 215A (PDF)​

Applicant Individual Information

[HSC section 1267.13(n)(o)] [22 CCR section 72201 and 72513(a)(1)]
This form must be completed for the following individuals and include signatures and dates:

  • Administrator of the facility
  • Owners, directors, board members, corporate officers, LLC members/managers, and partners of the organization and/or Management Company
  • Each individual having a beneficial interest of five percent or more in the 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 term 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

[HSC Section 1267.13(n)] [22 CCR section 72201]

A resume is required for the Administrator 

HS 309 1st Page​ (PDF)


Administrative Organization

[HSC section 1267.13(n)] [22 CCR section 72201]​

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

Supporting Documents​

Corporation

  • 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) and managers who are not members

HS 309 2nd Page​ (PDF)


Organizational Structure 

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

Copy of signed Resolution

​Supporting Documents

Partnership

Copy of signed Partnership Agreement

​​HS 400 (PDF)
Affidavit Regarding Patient Money

[HSC sections 1267.13(n) and 1318] [22 CCR section 72217]

  • Mark either A or B box. If B is checked, enter the amount of patient monies managed and submit the bond required on form HS 402

If handling less than $500 for all patients in any one month, a bond is not required.

​HS 402​ (PDF)

Surety Bond Verification 

[HSC sections 1267.13(n) and 1318] [22 CCR section 72217]

  • Is signed by the bonding agency
  • Possesses the embossed or raised seal of the bonding agency
  •  A copy of the is acceptable and does not have to be an original, however the embossed or raised seal of the bonding agency and Power of Attorney must be visible
  • Form is only required when applicable

Tips

  • Please check the upper right-hand corner of this form to ensure you are submitting the CA Department of Public Health form (not the Department of Social Services’ form)
  • ​Licensee name dba Facility name is acceptable​

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​

Floor Plan​

Floor Plan

[HSC section 1267.13]

Copy of facility’s floor plan that shows a schematic and level of care for each room

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 1267.13(n)] [22 CCR sections 72201, 72529(a)(10), and 72543 (e)]

  • Copy of “Purchase Agreement” or “Operating Transfer Agreement”
  • When applicable, written verification (with amount) by public accountant, accounting for all patient monies transferred to the custody of the new licensee. If none, need statement from current licensee that they did not handle resident monies
  • When applicable, copy of receipt (with amount) signed by the new licensee in exchange for such monies

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 



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