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EDMUND G. BROWN JR.
Governor

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



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.

Licensure

Home Health Agencies

 

Form #Item #​Description​Check-List​
​HS 200 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​​Licensure & Certification Application (Title 22, Section(s) 74661 & 74665)
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.3​Amount of Fee Enclosed.
[Title 22, Section 74669(a) and H&S Code, Section 1266]
​A.9​Age range of clients.
​A.10​Days and hours of operation.
​B.1

​Licensee’s name.

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

Owner type.
[Title 22, Section(s) 74603(a)(b) and 74661(a)(7)]

  • 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. [H&S Code, Section 1265(i)]
    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 Change of Ownership: 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” & “current” facility, agency or clinic.

  • Enter both agency names if this is a CHOW. If this agency does not have a separate facility name, they may insert the corporate name.
​C.3

​Address of “proposed” facility, agency or clinic

  • Indicate the address of “proposed” facility, agency or clinic
​C.6.a.

Name of Administrator and date of hire.

  • Insert the name of the Administrator and requested information. Administrator and Director of Patient Care Services can be the same individual.

[Title 22, Section 74718(b)]

​C.6.b

Name of Director of Nursing and date of hire.

  • Insert the name of the Director of Nursing and requested information. Director of Patient Care Services and Administrator can be the same individual.

[Title 22, Section 74718(b)]

​C.7.

Ownership.

  • List all individuals having 5% or more ownership, unless “nonprofit”.
  • Submit the HS 215A form for each of these individuals.
​C.8.

​Financial Resources.

The “specific” question on the HS 200 form does not apply to HHAs (only skilled nursing and intermediate care facilities). However, specific financial resources are required for a licensed “only” HHA (i.e., with no Medi-Cal or Medicare):
Any HHA that is going to be licensed “only” will need to submit evidence that the licensee has sufficient financial resources to operate the HHA for the first three (3) months. [Title 22, Section 74661(a)(6)]
This evidence should consist of the following:

  1. Projected expenses for the first three (3) months
    (90 days) of operation broken down by rent, utilities, salaries, overhead, etc.
  2. A copy of an “official” bank statement, certificate of deposit, etc. (in the name of the licensee) providing current balances.
​D.1.Property ownership.
​D.2.
  • ​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. Assignment & Assumption of Lease is acceptable as long as it states the Lease will become effective upon issuance of the license to the new licensee.

[Title 22, Section 74661(a)(3)]

​F.1

Signature.

  • Original “signature” is required and must be signed by the applicant (not the Administrator unless the owner is the Administrator).

 

Form #Item #​Description​Check-List​
​HS 215A ​ ​ ​ ​​Applicant Individual Information
[Title 22, Sections 74661(a)(5) & 74665]
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.
​Applicant Organization [Title 22, Section 74661(a)(5)]
  • For each individual having a beneficial interest of 5% or more in the applicant organization (list their ownership percentages) of the applicant organization.
  • For directors, board members, corporate officers,
    LLC members/managers, and partners of the applicant organization.

Parent Company [Title 22, Section 74661(a)(5)]

  • For each individual having a beneficial interest of 5% or more in the parent company (list their ownership percentages).
  • For directors, board members, corporate officers, LLC members/managers, and partners of the parent company.

Administrator of the Facility [Title 22, Section 78415(b)]

  • For the Administrator.
  • “Resume” for the Administrator. Compare with qualifications contained in Title 22, Section 74718.
  • Copy of Administrator’s professional license, if applicable.
  • Copy of Governing Body signed written statement verifying their appointment. [Title 22, Section 74613]

Administrator’s Designee

  • For Administrator’s Designee.
  • Administrative Designee resume.
  • Copy of Administrator Designee’s professional license, if applicable.

Director of Patient Care Services (DON)

  • For DON.
  • DON’s resume.
  • Copy of DON’s RN license.
​D​Employment/Business Summary.
  • A resume or attachment will be acceptable in lieu of Section “D” being filled out.
​Sign​​Signature.
  • Original “signature” is required on all the HS 215A forms.
​Facility 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 and address
  • Type of facility
  • Type of business entity (include EIN Number)
  • Individual’s nature and dates of involvement
  • This Sheet must also include any facilities licensed by the California Department of Social Services.

[Title 22, Section 74665(d)]

 

Form #Item #​Description​Check-List​
​HS 309
1st
page ​ ​ ​ ​
​Administrative Organization
(This form is not applicable for sole proprietor.)
​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.

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.
​9.

Governing Board of Directors.

  • Enter the number of board members or LLC members/holders.
  • Submit a list of board of directors or the LLC members/holders.
​10.​Enter the names of the board officers or the LLC officers/managers.
​HS 309 2nd page ​ ​ ​​1.

​Organizational Structure

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.

 

Form #Item #​Description​Check-List​
​HS 322 ​​Transmittal Application for Criminal Background Investigation

Submit the HS 322 form for the following individuals: [H&S Code, Section 1728.1(a)(2)(A)]

  • Owners (having a 5% or more ownership)
  • Administrator
  • Administrator’s Designee

Mail this form to the address indicated on the form.

​CDPH 325 ​​Criminal Record Clearance Submissions

Submit the CDPH 325 form with for the following individuals’ names listed on the form:
[H&S Code, Section 1728.1(a)(2)(A)] & Affordable Care Act

  • Owners (having a 5% or more ownership)
  • Administrator
  • Administrator’s Designee
​BCIA 8016 ​

​Request for Live Scan Service

For out-of-state fingerprint clearance, contact the Centralized Applications Unit at (916) 552-8630 or by e-mail: CAU@cdph.ca.gov

Instructions for completion of the BCIA 8016 form are available on the Attorney General’s website: http://ag.ca.gov/fingerprints/index.php

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/HealthFacility-HHA.aspx  

The ORI# must be “A1226”

Submit the BCIA 8016 form for the following individuals:

  • Owners (having a 5% or more ownership)
  • Administrator
  • Administrator’s Designee

 

Form #Item #​Description​Check-List​
​CMS 1572 (a)&(b)

​Home Health Agency Survey and Deficiency Report

If this HHA is a licensed “only”, the only reason this form is being requested is for the listing of the types of services.

  • Complete pages (a) and (b), items 1-20, as indicated on the form.
  • If this HHA is adding HOSPICE as a “service”, identify the Hospice service on page 2, Item 18, number 13 (under “Other”), of this form by writing in the word Hospice.
​Geog. Areas ​ ​​ ​ ​​Geographic Areas of HHA
(Title 22, Sections 74607, 74663, and 74664)
  • ​The service area of a parent HHA may not extend beyond four (4) hours surface travel time from the agency unless the agency serves a rural, scarcely populated area. So we may verify this, submit the service area documented on page 23 of the CMS- 855A application.

[Title 22, Section 74607(a)]

  • ​Both licensed and certified HHAs (parent and branch) must submit a list of geographical areas (including cities, counties & zip codes) to be served. This is required because a provider of HHA services cannot serve “All” of California.
​CHOW

​Change of Ownership

If there has been a previous CHOW in the last 36 months, you will need to apply for “Initial” licensure for Medicare certification purposes. Refer to the HHA Medicare forms identified on this checklist. [42 CFR, Section 424.550(b)] You must enroll as a “new” HHA. Undergo a State survey or obtain accreditation. Sign a new provider agreement.

Submit all of the forms required for an “initial” application, listed above, plus the following:

  • 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.

 



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