HEALTH CARE FACILITY LICENSING AND CERTIFICATION

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Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

For application status requests, please include the following in your email:

Application ID (if applicable)
Name of Facility or Agency
License or Facility/Agency # (if applicable)
Address
Facility or Provider Type
Date Documentation Sent
Contact Number

Home Health Agency

Add Branch Office Application Checklist

The following is a list of application forms and supporting documents required for a complete application packet. Failure to include each of the forms and documents will delay processing.

Add Branch Office

Checklist and Instructions - Please submit your documents in this order

Required Documents for Adding a Branch Office

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 of Parent Location of Parent and proposed Branch Facility name and ID number (if known) Brief description of request Contact information (name, title, phone number, and e-mail address) 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: California Health Alert Network (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 (Revised 7/2023) (Title 22 California Code of Regulation (CCR) section 74661(B)(3)) (Health and Safety Code (HSC) 1728) Tip Page 3, section A, item 9 – If the facility, agency, or clinic indicates they operate 24/7/365, complete “b” to indicate the hours of operations for the public. This information is used for surveying purposes Page 6, section B, Item 6 — An organization must own 100% of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN) Page 3, section B, Item 2 — When listing the names of individuals owning direct or indirect ownership of the facility in section C, provide the EIN (do not enter a social security number in this field)
Supporting Documents	IRS – Internal Revenue Service Documentation Submit one of the following IRS tax documents showing entity’s legal name and Tax Identification Number: Form 941- Employer’s Quarterly Federal Tax Return Form 8109- C FTD Address Change Letter 147-C- (EIN Confirmation Notification) Form SS-4- (Confirmation Notification)
Supporting Documents	B.3 - Organizational Chart - Owner Type Submit an organizational chart if the owner is a profit, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following: Applicant’s owners, including ownership %, directors, board members, corporate officers, LLC, members/managers, partners, and Tax ID/EIN # Parent company of applicant and all of the licensed agencies/facilities they are operating- see B.6
HS 200 (PDF, 1.5MB)	Section C.1 – Management Agreements Item B: HHA has no authority to allow management companies. The Skilled Nursing Facility (SNF) management companies’ authority cannot be used for an HHA. Additionally, interim management agreements between the proposed owner and the current owner cannot be accepted for HHA applicants.
Supporting Documents	Section D – Property Information Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee. If the licensee owns the property, submit a signed copy of the Grand Deed, or Bill of Sale If the licensee rent, lease, or sublease, submit the signed copy of the agreement (i.e., rental agreement and/or master lease between the property owner/manager and the perspective licensee)
Supporting Documents	Floor Plan Submit a floor plan that coincides with the room.
CMS 855A Page 23 (PDF)	Geographic Areas of HHA (Title 22 CCR sections 74607, 74663, and 74664) Page 23, Item F (only) List of Geographical Areas (cities, counties, zip codes) Web-based map reflecting the distance between the Parent and the Branch Office Branch offices cannot establish a new branch office outside of the HHA’s approved geographic service area
CMS 1572 (a) & (b) (PDF)	Home Health Agency Survey and Deficiency Report Complete pages (a) and (b), items 1-20, as indicated on the form.
CMS 855A (PDF)	Medicare General Enrollment Health Care Provider/Supplier Application The addition of a Branch Office must have prior approval from Centers for Medicare and Medicaid Services (CMS) for Certification of a HHA. Without prior approval, the provider cannot provide services to Medicare Patients. CMS will determine if the conditions of participation continue to be met with the addition of the new Branch Office. This application is from the Federal Department of Health and Human Services The completed application should be mailed directly to the appropriate fiscal intermediary

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