HEalth care facility licensing and certification

Hospice Agency

Report of Change Application Checklist for Change of Governing Board

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.
Please do not submit two-sided copies.

Required Documents for Change of Governing Board

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
Cover Letter	Cover Letter [Title 22 California Code of Regulations (CCR), § 74812(b)] Letter on company letterhead with the following information: License number Facility name and ID number (if known) Brief description of request Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address) The Department will use the invoice contact email address to invoice the application fee The Department will use the applicant contact email address to send all application correspondence General Contact Information (name, title, phone number, fax, email address, and alternative contact information) The Department will use this information to contact the facility for day-to-day business Emergency Contact Information (name, phone number, fax, email address, alternate email, 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) All Facility Letter Contact Information (name, phone number, fax, and email address) The Department will use this information to send All Facility Letters Facility Contact (Public Use) Information (phone number, fax, email address, and website address) The Department will use this information to store facility contact information for the public Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents The proposed name for the hospice, if altered due to a change of ownership Signature
HS 200 (PDF, 1.5MB)	Licensure & Certification Application (Revised 7/2023) [Health and Safety Code (HSC) 1749; Title 22 CCR § 74828(d), § 74812(c)]
Supporting Documents	Section A – Application Information [Title 22 CCR 74812 § (c)(1) – (c)(4), (c)(6) – (c)(7)] Page 3, item 9 - If the facility, agency, or clinic indicates they operate 24/7/365, complete "b" to identify business days and hours of operation of the hospice agency's commercial office. Page 3, item 10 - If the hospice agency is under construction, the application must include the following: A certiﬁcate of occupancy A copy of the construction approval form issued by the Department of Health Care Access and Information (HCAI) The actual or estimated dates of construction commencement and completion
Supporting Documents	Section B – Licensee Information [Title 22 CCR 74812 § (c)(9) – (c)(13), (c)(20)] The taxpayer identiﬁcation number or federal employer identiﬁcation number or both published by the Internal Revenue Service under the legal name of the applicant, or the social security number issued under the legal name of the applicant. (Submit one of the following) Form 941- Employer's Quarterly Federal Tax Return Form 8822 or 8822-B Change of Address Letter 147-C EIN Confirmation Notiﬁcation Form SS-4 Confirmation Notiﬁcation Filing statements endorsed by the California Secretary of State containing the date when the business was created, the business entity type, and the business entity number, if the applicant is applying as a business entity. A copy of the proposed or existing organizational chart displaying the names of the individuals or entities having authority or responsibility for the operation of the agency. If there is a parent organization the application must also include, but is not limited to: The parent organization's name, taxpayer identiﬁcation number or federal employer identiﬁcation number, and address A copy of the proposed or existing organizational chart displaying the names of the individuals or entities having authority or responsibility for the operation of the parent organization A list of all health facilities, clinics, and home health agencies the parent organization is operating, along with identifying any other agencies, facilities, clinics, or multiple locations that the applicant has been licensed for, operated, managed, held a ﬁve percent or more ownership interest or control interest, or services as a director or officer of, and the basis upon which the applicant exercises control and possession. This must include locations both within and outside the State of California
Supporting Documents	Section C – Facility, Agency, or Clinic Information [22 CCR 74812 § (c)(31)] A copy of the ﬁctitious name statement if the applicant will be operating under a different name other than the applicant's legal name
Supporting Documents	Section D - Property Information [22 CCR § 74812(c)(17) – (c)(19), § 74908] Submit the supporting documentation when the change includes a Change of Location or Property Owner. The property ownership information, including, but not limited to: The type of control of the property, including own, rent, lease, or sublease Evidence of control of the property, including, but not limited to, a copy of the grant deed, a bill of sale, a lease, or sublease agreement Name and address of the property owner or manager A ﬂoor plan, issued by the property owner, that coincides with the space If the property is leased, the tenant's name and physical address of the hospice If the property is subleased, the subtenant's name, physical address of the hospice, a copy of the master lease, and a letter that states the owner is aware of the sublet and the occupancy of the subtenant The hospice agency must be located in a commercial building either owned by the licensee or leased/sub-leased exclusively by the licensee for a minimum of 12 months Proof the applicant has obtained general liability insurance coverage for the hospice which covers the premises and operation. General liability insurance coverage limits must not be for an amount less than $100,000 per claim nor a minimum annual aggregate of not less than $300,000 Proof the applicant has obtained and maintains worker's compensation coverage for the hospice that covers the premises and operation. Worker compensation coverage limits must not be for an amount less than $100,000 per claim nor a minimum annual aggregate of not less than $300,000
	Section F – Subcontractor Information and Signiﬁcant Business Transactions [22 CCR § 74812(c)(34)] If the current or proposed facility, agency, or clinic, is applying for Medi-Cal certiﬁcation, complete attachment F-1: Subcontractor Information and Signiﬁcant Business Transaction (Previously referred to as DHCS 6207 – Medi-Cal Disclosure Statement)
Supporting Documents	Section G – I (We) Accept Responsibility to [Title 22 CCR 74812 § (c)(8)] One form of current and valid photo identiﬁcation which veriﬁes that the individual completing the application is age 18 years or older. Proof of identity includes, but is not limited to, a driver's license or state identiﬁcation card issued by the Department of Motor Vehicles, United States or foreign passport or passport card, or United States military card or military dependent's ID card
HS 215A (PDF)	Applicant Individual Information (Revised 7/2023)
Supporting Documents	[Health and Safety Code (HSC) § 1749; Title 22 CCR § 74812(c)(22)] HS 215 A is required for: Any individual with ﬁve percent or more direct or indirect ownership interest or control interest in the hospice Directors, board members, corporate officers, limited liability company members and managing partners Administrator Administrator Designee Directors of Patient Care Services Director of Patient Care Services Designee Medical Director Medical Director Designee
Supporting Documents	Guidelines: Section B – Applicant Individual Information [Health and Safety Code (HSC) § 1749; Title 22 CCR § 74812(c)(22), 74876, 74852, 74856] Page 2, 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, item 4 – Individuals must submit one form of current and valid photo identiﬁcation which veriﬁes that the individual is 18 years or older. Proof of identity includes, but is not limited to, a driver's license or state identiﬁcation card issued by the Department of Motor Vehicles, United States or foreign passport or passport card, United States military card, or military dependent's ID card. Page 2, 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 3, item 7 – Administrator and Designee, list the number of hours spent at each agency per week
Supporting Documents	Section E – Employment History [Health and Safety Code (HSC) § 1749; Title 22 CCR § 74812(c)(22), 74876, 74852, 74856] 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, if serving as management personnel the following is required: A resume is required to be submitted to determine qualiﬁcations for the management personnel position Resume must include, but not limited to, employment history and contact information for the last ten years of employment, unemployment, and education history Contact information for previous employers includes, but is not limited to, the name, phone number, and e-mail address for previous employers
Supporting Documents	Section H – Facility Information Sheet [Health and Safety Code (HSC) § 1749; Title 22 CCR § 74812(c)(22), 74876, 74852, 74856] 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
	Applicant Release Declare under penalty of perjury the statements on the application and accompanying attachments are correct Applicant signature and date Applicant printed name and title
HS 309 Page 1 (PDF)	Administrative Organization [Title 22 CCR § 74812(c)(10)] Submit the following supporting documents according to organizational type:
Supporting Documents	For-Proﬁt or Non-Proﬁt Corporations Filing Statement endorsed by the Secretary of State Signed Articles of Incorporation Signed By-Laws
HS 309 Page 2 (PDF) Supporting Documents	Organizational Structure [Title 22 CCR § 74812(c)(10)] Limited Liability, Limited, or General Partnership Copy of signed Partnership Agreement Filing Statement endorsed by the Secretary of State Signed Articles of Organization Signed Operating Agreement
CMS 855A (PDF)	Medicare General Enrollment Health Care Provider/Supplier Application For awareness: [Title 22 CCR § 74812(c)(33)] 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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