Health care facility licensing and certification

Hospice Agency

Report of Change Application Checklist for Change of Director of Patient Care Services and Director of Patient Care Services Designee

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 a Change of Director of Patient Care Services and Director of Patient Care Services Designee

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

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 215A (PDF)

Supporting Documents

Applicant Individual Information

(Revised 7/2023)

[Title 22 CCR § 74812(c)(22 – 30), § 74852]

The hospice governing body must appoint an administrator in writing
The Administrator must appoint a Designee in writing, who meets the requirements
Fully endorsed copy of the executed employment contract
Any individual that has had disciplinary action taken against them within the last seven years is not eligible to serve as management personnel

Supporting Documents

Guidelines:

Section B – Applicant Individual Information

[Health and Safety Code (HSC) § 1749; 22 CCR § 74812(c)(22), § 74852]

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

Supporting Documents

Section E – Employment History

[Health and Safety Code (HSC) § 1749; 22 CCR § 74812(c)(22), § 74852]

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 it not limited to, the name, phone number, and e-mail address for previous employers
A list of all hospices an individual is currently serving as administrator, administrator designee, director of patient care services, director of patient care services designee, medical director, or medical director designee

Section H – Facility Information Sheet

[Health and Safety Code (HSC) § 1749; Title 22 CCR § 74812(c)(22), § 74852]

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: