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
• 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/po​sition, mailing address, phone number, and email address)
• Signature
  

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

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 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) 

• Page 1, item 3 — The incorporation date is located in the top right corner of the applicant Articles of Incorporation​

Public Agency

Copy of signed Resolution