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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 Branch Office

Home Health Agencies

A Branch Office:

  • means a HHA established and administered by a parent HHA, providing services within a portion of the total service area served by the parent agency.
  • is located at a separate location from the parent and must offer the same services as the parent.
  • is listed on the parent license. (Title 22, Section 74675)
  • is required to submit a separate application package consisting of the forms identified on this checklist.​
Form #Item #​Description
Branch Office​
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.

Note: 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.

​Indicate the address of “proposed” facility, agency or clinic.

  • The Branch Office address must be listed on the parent license [Title 22, section 74661(a)(3)]
​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.
D.2.

​Property ownership.

  • 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).
​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.

 

Form #Item #​​DescriptionCheck-List​
​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 – Branch Office
​Complete and submit:
  • ​HS 200 form
  • ​Application Fee
  • ​HS 215A form

 



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