HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Congregate Living Health Facility and Pediatric Day Health and Respite Care Facility

Report of Change Application Checklist for Change of Governing Board

The following is a list of forms and supporting documents required for a complete application packet. Failure to include every form or document will delay processing or lead to denial.

Checklist and Instructions - Please submit your documents in this order and save a copy of all submitted documents for your records.

Required Documents for a Change of Governing Board

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 Contact information (name, title, phone number, and e- mail address) Facility Contact (public phone number, public fax number, public email address, and public webpage). The Facility Contact (Public Use) information is used to store facility contact information for the public. 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, 1.5MB)	Licensure & Certification Application CLHF and PDHRC: [Title 22 California Code of Regulations (CCR) section 72211] [Health and Safety Code (HSC) section 1267.13(n)] PDHRC: [HSC section 1760.4(c)] Tips: Page 6, section B, item 6 — An organization will have its own Federal tax ID number Signature must be from the applicant (Licensee/owner), not the Administrator, unless the owner is the Administrator.
Supporting Documents	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
HS 215A (PDF)	Applicant Individual Information CLHF and PDHRC: [22 CCR section 72211] [HSC section 1267.13(n)] PDHRC: [HSC section 1760.4(c)] This form must be completed for the following individuals and include original signatures: New directors, board members, corporate officers, LLC members/managers, and/or partners of the applicant 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 and attach the 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
HS 309 1st Page (PDF)	Administrative Organization CLHF and PDHRC: [HSC section 1267.13(n) and 1760.4(C)] [22 CCR section 72211] 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 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
Supporting Documents	Limited Liability Company (LLC) Filing Statement from the Secretary of State Articles of Organization LLC Operating Agreement Foreign (out-of-state) applicants submit a copy Certificate of Qualification from the California Secretary of State List of Managing Members (only if additional space is needed to input all managing members) and managers who are not members Tip Page 1, item 3 — The incorporation date is located in the top right corner of the applicant Articles of Organization
Supporting Documents	New Board Member Verification Documentation verifying the appointment of new Board Member(s), such as copy of board meeting minutes, appointment letter, resolution etc.
HS 309 2nd Page (PDF)	Organizational Structure Only complete fields that are applicable to applicant’s entity type
Supporting Documents	Public Agency Copy of signed Resolution
Supporting Documents	Partnership Copy of signed Partnership Agreement

Note: Save a copy of all submitted documents for your records.

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