Hospice Agency and Hospice Facility
Report of Change Application Checklist for Change of Administrator
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 a Change of Administrator
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Forms and Supporting Documents
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Additional Instructions
(Each form listed also has instructions on the form)
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Cover Letter
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Cover Letter
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) General Contact Information (name, title, phone number, fax, email address, and alternative contact information) Emergency Contact Information (name, phone number, fax, email address, alternate email, and phone number that will receive text messages) All Facility Letter Contact Information (name, phone number, fax, and email address) Facility Contact (Public Use) Information (phone number, fax, email address, and website address) Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)
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HS 215A (PDF)
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Applicant Individual Information
(Revised 7/2023)
[Health and Safety Code (HSC) section 1748(b); Standards of Quality Hospice Care (SQHC), 2003, section 5.1]
This form must be completed for administrators and include signature:
Tips:
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 Page 3, section B, item 7 – Administrator must list the number of hours spent at each agency per week. 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
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HS 215A (PDF)
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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 Facility address Type of facility Type of business entity (include EIN Number) Individual's nature of involvement Individual's dates of involvement
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Supporting Documents
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Resume A resume required for the Administrator.
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