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

• ​Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address)

• The Department will use the invoice contact email address to invoice the application fee

• The Department will use the applicant contact email address to send all application correspondence

General Contact Information (name, title, phone number, fax, email address, and alternative contact information)

• The Department will use this information to contact the facility for day-to-day business

Emergency Contact Information (name, phone number, fax, email address, alternate email, 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)

All Facility Letter Contact Information (name, phone number, fax, and email address)

• The Department will use this information to send All Facility Letters

Facility Contact (Public Use) Information (phone number, fax, email address, and website address)

• The Department will use this information to store facility contact information for the public

• Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)

• The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents​

• Signature
  

​B.3 - Organizational Chart - Owner Type

CLHF and PDHRC: [HSC section 1267.13(n) and 1760.4(c)] [22 CCR section 72211]

Submit a before and after 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 new individual

• Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating – see B.6

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

Corporation

• Filing Statement from the Secretary of State

• Articles of Incorporation

• By-Laws

• Foreign (out-of-state) applicants submit a copy Certificate of Qualification from the California Secretary of State

• 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​

​New Board Member Verification 

Documentation verifying the appointment of new Board Member(s), such as copy of board meeting minutes, appointment letter, resolution etc.

Public Agency

Copy of signed Resolution