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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health



Chronic Dialysis Clinic: Initial Licensure or Change of Ownership
Applicant Checklist

The following is a quick reference of some of the questions found on the required forms. It includes the form number, name of form, and an explanation of specific requirements and/or attachments needed for specific forms. This is not an all-inclusive list of the questions that need to be answered so read the questions and instructions on each form.

Note: All forms listed are in PDF format.

Form #​Item #​Description​Check List

HS 200 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​

Licensing & Certification Application (H&S Code Section 1212)
Note: Please read the instructions on the HS 200 form prior to completion of the form. The items listed below are the most common items that are not completed correctly – however, these are not all of the items listed on each form.

 

​​A.11.

​Construction 

If this is a newly constructed and/or remodeled building, submit the following for "initial" applications (N/A for CHOWS unless there has been construction and/or remodeling):

  • Written certification of Title 24 compliance (OSHPD 3 Standards) from a California licensed architect or a
    local building authority.
    • The written statement must state that the building meets the following:
      • California Building Code
      • California Electrical Code
      • California Mechanical Code
      • California Plumbing Code
    • The California licensed architect or local building authority may use the “Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital” (CDPH 270) to certify that the facility conforms to current applicable Title 24 California Building Standard Codes (OSHPD 3 Standards) in lieu of a written statement.
  • Certificate of Occupancy
    • If this clinic is not a previously licensed clinic, submit the Title 24 requirements (OSHPD 3 Standards) listed above.
​B.1

​Licensee's Name

  • The licensee's formal organization name must be consistent throughout all documents.
​​B.3.​​Owner type

Submit an organization chart/flow chart if the owner is a profit or nonprofit corporation, limited liability company (LLC), or general partnership. The organization chart needs to display the following:

  • Applicant’s owners, directors, board members, corporate officers, LLC members/managers, and 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.
​B.5.a.​Licensee’s "other" facility involvement
  • Answer all aspects of the question.
​​B.5.b.​Revocation, suspension, etc. action
  • If applicable to the licensee, submit the information requested.
​​B.6.​Subsidiary (Parent Company) Information

If there is a “subsidiary” (parent company) submit:

  • An organization chart with the parent company name.
  • A listing of all owners, directors, board members, corporate officers, LLC members/managers, and partners of the parent company.
    Note: Submit the HS 215A form for each of these individuals.
  • A listing of all facilities the parent company is operating.
​​C.1.b​"Interim" Management Company Agreement
  • Note if CHOW: If there is an "interim" Management Company Agreement, between the current and the prospective licensee, submit a signed and dated copy of Agreement.
​​C.2.​Name of "Proposed" and "Current" Agency
  • Enter both facility names if this is a CHOW.
​​C.6.a​Administrator
  • Submit the HS 215A form for the administrator of the facility.
​​C.6.b​Director of Nursing
  • Insert director of nursing name.
​​C.7.​Ownership
  • List all individuals having 5% or more ownership, unless "nonprofit."
  • Submit the HS 215A form for each of these individuals.
​D.1.
D.2.
​Property Ownership
  • 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.
​​F.1.​Signature
  • Original "signature" is required and must be signed by the applicant (not the administrator unless the owner is the administrator).

HS 215A​ ​ ​ ​

​ ​ ​ ​ ​ ​

​Applicant Individual Information (H&S Code Section 1267.5)
Note: Please read the instructions on the HS 215A form prior to completion of the form.

This form must be completed for the following individuals with original signatures:

  • Administrator of the facility with his or her resume
  • Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization and/or management company.
  • Each individual having a beneficial interest of 5% or more in the applicant organization and/or parent organization[H&S Code Section 1267.5(a)(1)].
​​Sign​Signature
  • Original "signature" is required.
​​Fac Info Sheet​​Facility Information Sheet
If applicable, each individual must complete and submit the “Facility Information Sheet” for each facility and/or agency with which they have a current or past relationship within the last 3 years. 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
  • This Sheet must also include any facilities licensed by the California Department of Social Services.

HS 309 1st page ​ ​ ​ ​

​​ ​Administrative Organization ​
​2.​Administrator of Corporation or LLC – This is usually the CEO/President.
​3. - 7.​Corporations need to submit:
  • Copy of the Filing Statement from CA Secretary of State (only required if Articles of Incorporation are not endorsed by the CA Secretary of State).
  • Copy of all Articles of Incorporation (endorsed by CA Secretary of State).
  • Copy of By-Laws.
  • List of board of directors - submit the HS 215A form for each individual listed under this item.

LLCs need to submit:

  • Copy of the Filing Statement from CA Secretary of State (only required if Articles of Organization are not endorsed by the CA Secretary of State).
  • Copy of all Articles of Organization (endorsed by CA Secretary of State).
  • Copy of Operating Agreement.
  • List of members, holders, officers, managers - submit the HS 215A form for each individual listed under this item.
​9.​Governing Board of Directors
  • Enter the number of members/managers.
  • Submit the HS 215A form for each individual listed under this item.
​10.​Board Officers and/or LLC Members/Managers
  • Submit the HS 215A form for each individual listed under this item.

HS 309

2nd page ​ ​ ​ ​
​Organizational Structure ​
​1.​California Out-of-State Corporations, LLC, etc.
  • Submit a copy of the Certificate of Qualification from the California Secretary of State
​3. & 4.​Public Agency
  • Submit a copy of the signed Resolution.
​5.​​Corporations, LLCs, and Partnerships need to complete. N/A for nonprofit.
​Bottom of page​​Partnerships need to submit:
  • A copy of the Partnership Agreement
  • Copy of the California Secretary of State filing, if applicable.
  • HS 215A form for each partner
HS 602

Transfer Agreement

  • Please submit a copy of the Transfer Agreement. The Transfer Agreement needs to be current (within one year).

​STD 850

​Fire Safety Inspection Request
  • This form is not required for a CHOW.
  • The STD 850 form must be submitted or a similar form from the fire authority. If the STD 850 form is not submitted, the fire authority form will need to contain equivalent information as the STD 850 form.
​DHCS 1051

​Civil Rights Compliance Review

  • Send directly to the Office of Civil Rights - address is on the last page of the form.
​CHOW​Change of Ownership (CHOW)

Submit the following:

  • All of the forms required for an "initial" application listed above.
  • Copy of "Purchase Agreement" or "Operating Transfer Agreement."
  • 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 [Title 22 CCR Section 70751(e)].


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