General Acute Care Hospitals and Acute Psychiatric Hospitals
Change of Ownership
Required Documents
Online Application PDF Form
- Embedded and generated by online system
Change of Ownership
- āPurchase Agreement or Operating Transfer Agreementā
- 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: applicantās 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 Stateāāā
Entity Organization
- āFiling Statement from the Secretary of State
- Please submit the following documents based on the applicable ownership type:
- āCorporation - Submit Articles of Incorporation and By-Laws
- LLC - Submit Articles of Organization and Operating Agreement
- Public Agency - Submit Copy of signed Resolution
- Partnership - Submit Copy of signed Partnership Agreement
- āāList of Board of Directorsāā
Facility Director of Nursing
- Resume for the 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)ā
Patient Money Affidavit (Only required when applicable
- āHS 402 (PDF) form ā Surety Bond Verification ā
- āHS 400 (PDF) form ā Affidavit Regarding Patient Money
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/responsibilitiesā
Facility Information - Medicare Certification Documents (Only applicable for Medicare Certification)
- āCMS 1561 (PDF) form - Health Insurance Benefit Agreement
- HS 328 (PDF) form - Notice-Effective Date of Provider Agreement
- HHS 690 (PDF) form - Assurance of Compliance (Submit a verification from the Office of Civil Rights displaying submission of this form)
Facility Information - Medi-Cal Certification Documents (Only applicable for Medi-Cal Certification)
- DHCS 9098 (PDF) form ā Medi-Cal Provider Agreement
- DHCS 6207 (PDF) form ā Medi-Cal Disclosure Statement (Only submit Section V ā Subcontractor Information and Significant Business Transactions)
- One of the following Internal Revenue Service tax documents: ā
- Form 941 ā Employerās Quarterly Federal Tax Return
- Form 8109-C ā FTD Address Change
- Letter 147-C ā EIN Verification Letterā
- Form SS-4 ā Application for Employer Identification Number
- HS 328ā (PDF) form - Notice-Effective Date of Provider Agreementā
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