Skip Navigation LinksHospice-HOFA-CHGB-Provider-Checklist


 Contact Us

Phone: (916) 552-8632

For application status requests, please include the following in your email:

  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Number​​​​​​​​

Hospice Agency and Hospice Facility 

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

Required Documents for Change of Governing Board 

Forms and Supporting​ Document​s​​​

Additional Instructions

(Each form listed also has instructions on the form)

Cover Letter

Cover Letter

Letter on company letterhead with the following information:

  • License number
  • Facility name and ID number (if known)
  • Brief description of request
  • Contact information (name, title, phone number, and e- mail address)
  • Emergency Contact Information (name, email, alternate email, phone, fax, 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 (
  • Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address) 
  • Signature
HS 200 (PDF, 1.5MB)

Licensure & Certification Application

(REVISED 07/2023) [Health and Safety Code (HSC) section 1748(b)].


  • Page 3, section A, item 9 – If the facility, agency, or clinic indicates they operate 24/7/365, complete “b" to indicate the hours of operations for the public. This information is used for surveying purposes.
  • Page 3, section B, item 2 –Provide the EIN of the licensee. Do not enter a Social Security number in this field.
  • Page6, section B item 6: An organization must own 100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN)
Supporting Documents

B.3 – Organizational Chart – Owner Type

Submit an organizational chart if the owner is a For-Profit Corporation, General Partnership, Limited Liability Company (LLC), Limited Liability Partnership, Limited Partnership, Nonprofit. The organizational chart needs to display the following:

  • Applicant's owners, including ownership percentages, Tax ID/EIN # and all directors, board members, corporate officers, LLC members/managers, and/or partners
  • If the licensee is a subsidiary of another organization Licensee identified in Section B.1. Submit an organizational chart to display the relationship
  • Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating- see B.6 
​Note: Submit the HS 215A form for each of these individuals

HS 215A (PDF)

Applicant Individual Information

[HSC section 1748(b); Standards of Quality Hospice Care (SQHC), 2003, section 6.1]

This form must be completed and signed for the following individuals and include original signatures:

  • Administrator, Administrator Designee and the Director of Patient Care Services of the facility
  • Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization
  • Each individual having a beneficial interest of exceeding 5 percent or more in the applicant organization and/or parent organization

  • Page 2, section B, 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, section B, item 4 – Provide your Driver's License Number or a State-Issued identification Card Number. Attached a copy of the Driver's License or State-Issued Identification Card for verification.
  • Page 2, section B, 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 [LNL1] 
  • Page 5, section E — 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, the resume must contain all required information requested in section D
  • Page 7, section F — If answering yes to any question in this section, complete Section H, Facility Information Sheet

Supporting Documents

Section H - Facility Information Sheet

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
  • Address (Number & Street), City, State, and Zip (9-digit)
  • Facility Type,
  • Individual's Nature of Involvement
  • Dates of Involvement (From and To)
  • Entity Name
  • Type of Business Entity
  • Business Entity Employer Identification Number (EIN)
  • Are any of the above Business Entities a “PARENT" organization to the applicant facility in Section A? 

HS 309 Page 1 (PDF)

Administrative Organization

Along with the HS 309, the following supporting documents according to organizational type must be submitted:

Supporting Documents


  • Filing Statement from the Secretary of State
  • Articles of Incorporation
  • By-Laws
  • List of Board of Directors (only if additional space is needed to input all board of directors)


  • Page 1, item 3 — The incorporation date is located in the top right corner of the applicant Articles of Incorporation

Supporting Documents

Limited Liability Company (LLC)

  • Filing Statement from the Secretary of State
  • Articles of Organization
  • Operating Agreement
  • List of Managing Members (only if additional space is needed to input all managing members)

HS 309 Page 2 (PDF)

Organizational Structure

Only complete fields that are applicable to applicant’s entity type


  • Page 2, item 1 - Health care districts will fill in the circle for other​
Supporting Documents

Public Agency

Copy of signed Resolution

Supporting Documents


Copy of signed Partnership Agreement​​

Page Last Updated :