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EDMUND G. BROWN JR.
Governor

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



Hospice Facility: Additional Site - Licensure
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.

Note: All forms listed are in PDF format.

Form #​Item #​Description​Check List
HS 200 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​Licensing & Certification Application [H&S Code Section 1748(b) & 1749(a)(3)]
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 [H&S Code Section 1748(a)]

  • A fee is also required for additional hospice sites.
​​A.4.c​Change of Location
  • A licensed hospice and a separately licensed HHA cannot share the same space but CAN be in the same building with a different address, phone number, staff, etc.
​A.5.o.

Facility Type

  • Enter "Hospice Facility"
​​A.9.​Age range of clients
  •  Age range needed especially for pediatric hospice.
​​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

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.
  • 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.
  • A listing of all facilities the parent company is operating.
​​C.1.b​"Interim" Management Company Agreement
  • Note if CHOW: 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" and "Current" Agency
  • Enter both hospice names if this is a CHOW.
  • The applicant may insert the corporate name if there is no hospice name.
​​C.3.​Address of "Proposed" Facility, Agency, or Clinic
  • List the address of the parent hospice first.
  • The additional hospice site addresses must be listed after the parent address. They do not need a separate license [H&S Code Section 1748(a)].
  • A "licensed" HHA and a "licensed" freestanding hospice cannot be located in the same office.
  • A "licensed and certified" HHA and a "certified-only" hospice program can be located in the same office.
​​C.6.b​Director of Nursing and Date of Hire
  • Submit their resume (SQHC, Section 5.3, Director of Patient Care Services).
​​C.7.​Ownership
  • List all individuals having 5% or more ownership, unless "nonprofit."
​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.
​​F.1.​Signature [H&S Code Section 1749(a)(3)]
  • Original "signature" is required and MUST be signed by the applicant (not the Administrator unless the owner is the Administrator).
Hospice Svs​Hospice Services
  • Must provide, or make provisions for the basic services listed below: (H&S Code Section 1749(b)(1) through (b)(7) and SQHC, Section 2.1. Services Provided)
    • Skilled nursing services
    • Social services/counseling services
    • Medical direction
    • Bereavement services
    • Volunteer services
    • Inpatient care arrangements
    • Home health aide services
  • Note: All services provided by the additional hospice sites and parent hospice [H&S Code Section 1746(n)].
  • Note:  Services for additional Sites have to be the same as their parent [H&S Code Section 1746(k)].
​DO to review
​Geog. Areas​Geographic Areas of Hospice
  • Submit web-based map reflecting the distance between the parent ant the additional hospice site, if this is an additional hospice site.
  • Additional hospice sites cannot establish a new additional site outside of the hospice’s approved geographic service area.


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