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: [22 CCR section 72211(a)]

CLHF: [HSC section 1267.13(n)]

PDHRC: [HSC section 1760.4(c)]

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 of these individuals

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

​Applicant Individual Information 

CLHF and PDHRC: [22 CCR section 72211(a)]

CLHF: [HSC section 1267.13(n)]

PDHRC: [HSC section 1760.4(c)]

This form must be completed and signed for the following individuals:

• New owners, directors, board members, corporate officers, LLC members/managers, and/or partners of the organization

• Each individual having a beneficial interest of five percent or more in the organization and/or parent 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
  

Administrative Organization

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

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

​Limited Liability Company (LLC)​​

Public Agency​

Copy of signed Resolution