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HEALTH CARE FACILITY LICENSING AND CERTIFICATION​

 Contact Us

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

Report of Change Application Checklist for Change of Stock Transfer

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.

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of Stock Transfer

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

  • Facility name and ID number (if known)

  • Brief description of request

  • Contact information (name, title, phone number, and email 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: 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 Regulations (CCR) section 74661 and 74667(b)(3); (Health and Safety Code (HSC) section 1728)]

Tips:​

  • 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 3, section B, item 2 –Provide the EIN of the licensee. Do not enter a Social Security number in this field.

  • Page 6, section B, item 6 — An organization must own 100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN)​

Supporting Documents 

B.3 – Organizational Chart – Owner Type

[CCR sections 74661(a)(7) and 74667(b)(3) (HSC section 1728)]​

Submit an organizational chart if the owner is a For-Profit Corporation, General Partnership, Limited Liability Company (LLC), Limited Liability Partnership, Limited Partnership, and Nonprofit. 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

  • If the licensee is a subsidiary of another organization Licensee identified in Section B.1, submit an organizational chart to display the relationship 

  • Parent company of applicant, if applicable, and all the licensed agencies/facilities it is operating - see B.6

  Note: Submit the HS 215A form for each of these individuals​

Supporting Documents

Stock Purchase Agreement

[HSC section 1728]​

Copy of the signed Purchase Agreement

HS 215A (PDF)

Applicant Individual Information (REVISED 7/2003)

[CCR section 74661 (a)(5) & 74665 (HSC section 1728)]
 
This form must be completed and signed for the following individuals and include original signatures:
 

  • Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization 
  • Each individual having a beneficial interest of five percent or more in the applicant organization and/or parent organization​

Tips:​

  • Page 2, section B, item 3 — 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 2, section B, item 4 – Provide your Driver's License Number or a State-Issued identification Card Number. Attached a copy of the Driver's License or State-Issued Identification Card for verification. 
  • Page 2, section B, item 5 – The Social Security Number is an identifier, as several people may have the same name. this will ensure 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 D; however, the resume must contain all required information requested in section D
  • Page 7, section F — If answering yes to any question in this section, complete Section H, Facility Information Sheet

​Supporting Documents 

Section H - Facility Information

Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. 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

HS 309 1st Page (PDF)


Administrative Organization

[22 CCR section 74661]​

Along with the HS 309, depending on organizational type, the following supporting documents must be submitted:

Supporting Documents

​Corporation

  • Filing Statement from the Secretary of State
  • Articles of Incorporation
  • By-Laws
  • List of Board of Directors (only if additional space is needed to input all board of directors)

    Tip:
  • ​​Page 1, item 3 — The incorporation date is located in the top right corner of the applicant Articles of Incorporation​
Supporting Documents

​Limited Liability Company (LLC)​

  • Filing Statement from the Secretary of State

  • Articles of Organization

  • Operating Agreement

  • ​List of Managing Members (only if additional space is needed to input all managing members)

HS 309 2nd Page (PDF)


Organizational Structure

Only complete fields that are applicable to applicant’s entity type

Supporting Documents

​Public Agency

Copy of signed Resolution​

Supporting Documents

Partnership

Copy of signed Partnership Agreement
​HS 322 (PDF)

​Transmittal Application for Criminal Background Investigation

[HSC section 1728.1(a)(2)(A)]​

Submit the HS 322 form for the following individuals:​

  • Owners with a five percent or more direct or indirect ownership

  Note: Mail this form to the address indicated on the form


​Criminal Record Clearance Submissions

[HSC section 1728.1(a)(2)(A)]​

Submit the CDPH 325 form with for the following individuals' names listed on the form:​

  • Owners with a five percent or more direct or indirect ownership

  • Administrator 

BCIA 8016​ (PDF)

Request for Live Scan Service

The BCIA 8016 form is required for an owner (having a 5% or more ownership).

For out-of-state fingerprint clearance it is necessary to request exemption for Live Scan and have “wet" fingerprints rolled by a local law enforcement agency, contact the Centralized Applications Branch to obtain forms BC119004 and FD-258 at (916) 552-8632 or by e-mail: CAB@cdph.ca.gov.

  Tips:​

  • Refer to the “Sample" BCIA 8016 form on the L&C “Applications for a Home Health Agency" website: https://www.cdph.ca.gov/ Programs/CHCQ/LCP/Pages/HealthAgency-HHA.aspx 

  • Additional BCIA 8016 form instructions are available on the Attorney General's website:https://oag.ca.gov/fingerprints​ The ORI# must be “A1226."​


Medi-Cal Certification Documents 

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

DHCS 9098 (PDF) 
Medi-Cal Provider Agreement

If the majority owner is changing and the agency accepts Medi-Cal, an updated agreement with the new majority owner's signature is required.​

  Tips:

  • Do not leave any questions blank. Enter “same" or “N/A" if not applicable
  • The mailing address must be the same as reported on the HS 200 form
  • Notarized signature page is required
  • Submit the "Acknowledgement" page from the notary public, if applicable​


Medicare Certification Documents 

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

CMS 855A (PDF)
Medicare General Enrollment Health Care Provider/Supplier Application
 

If the majority owner is changing and the agency accepts Medicare, an updated agreement with the new majority owner’s signature is required:

  • 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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