HEALTH CARE FACILITY LICENSING AND CERTIFICATION

General Acute Care Hospitals and Acute Psychiatric Hospitals

Online Application PDF Form

Change of Ownership

Purchase Agreement or Operating Transfer Agreement
Written verification (with amount) by public accountant, accounting for all patient monies transferred to the custody of the new licensee or a statement from the current licensee that resident monies were not handled (only when applicable)
Copy of receipt (with amount), signed by the new licensee in exchange for such monies (only when applicable)
Letter from prospective licensee to the California Department of Public Health stating where the stored patient medical records will be maintained, and that the records will be made available to the previous licensee

Licensee/Business Entity Information

Organizational chart displaying the following information: applicant’s owners, directors, board members, corporate officers, LLC members/managers, and partners

The organization chart needs to include all entities that have 5% or more direct and indirect ownership

Foreign or out of state corporations, LLCs, and partnerships need to submit Certificate of Qualifications from the California Secretary of State

Entity Organization

Facility Director of Nursing

Facility Property Information - Onsite

Copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee
Floor plan that includes a schematic of the room(s)

Facility Property Information - Offsite (Only applicable for offsite construction

Copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee
Floor plan that includes a schematic of the room(s)

Patient Money Affidavit (Only required when applicable

Subcontractor Information (Only required when applicable)

Copy of any written agreement(s) that Licensee/Business Entity has with the subcontractor that relate to its functions/responsibilities

Facility Information - Medicare Certification Documents (Only applicable for Medicare Certification)

Facility Information - Medi-Cal Certification Documents (Only applicable for Medi-Cal Certification)

DHCS 9098 – Medi-Cal Provider Agreement (PDF, 2.9MB)
DHCS 6207 – Medi-Cal Disclosure Statement (PDF) (Only submit Section V – Subcontractor Information and Significant Business Transactions)
One of the following Internal Revenue Service tax documents: