Health care Facility Licensing and Certification

Contact Us

Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

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

Initial and Change of Ownership Multiple Location Application Checklist

Effective January 1, 2022, Senate Bill (SB) 664 institutes a moratorium on new hospice license. During the moratorium, CDPH will be prohibited from issuing a new license pursuant to Health and Safety Code (HSC) section 1751.70. However, according to HSC section 1751.75, CDPH may grant an exception to the moratorium.

Step 1: Individuals or entities interested in applying for hospice licensure must begin by submitting an exception request. This consist of submitting a written justification and supporting documentation to demonstrate need based on geographic concentration to the Centralized Applications Branch (CAB). If CAB determines there is a need based on geographic concentration, CAB will notify the applicant they may apply for licensure. Do not submit the required documents listed in the table below for licensure prior to submitting an exception request and receiving CAB determination.

Stop Here: If you have submitted an exception request, and CAB denied your request you are denied submitting an application. Do not submit an application seeking hospice licensure. Pursuant to SB 664 and HSC 1751.70, CDPH cannot issue you a license to operate a hospice.

For additional information, please refer to AFL 21-53 on the CDPH website (www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-21-53.aspx).

Step 2: If you received notice from CAB that your exception request was accepted, you may submit an application to CAB with a copy of your acceptance letter. 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.

Initial License
Change of Ownership (CHOW)

Checklist and Instructions - Please submit your documents in this order

Required Documents for an Initial License or CHOW

Forms and Supporting Documents	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 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 (https://calhospital.org/calhospitalprepare/) 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
SB 664 Supporting Document	Attach a copy of your SB 664 – hospice moratorium acceptance letter received from CAB.
Information	Pursuant to 42 CFR 418.100(f), If a hospice operates multiple locations, it must meet the following requirements. (1) Medicare approval i. All hospice multiple locations must be approved by Medicare before providing hospice care and services to Medicare patients. ii. The multiple location must be part of the hospice and must share administration, supervision, and services with the hospice issued the certification number. iii. The lines of authority and professional and administrative control must be clearly delineated in the hospice's organization structure and in practice, and must be traced to the location which was issued the certification number.
HS 200 (PDF, 1.5MB)	Licensure & Certification Application (Revised 07/2023) [Health and Safety Code (HSC) section 1748(b)]. Tip: 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)
HS 200 - Supporting Documents	Section B - Licensee Information (Page 3): Item 1: Licensee legal name as reported to the IRS Ensure the Licensee legal name matches the supporting document listed below. Item 3: Federal Tax Identification Number/Employer Identification Number (EIN): Submit one of the following IRS tax documents showing the licensee’s legal name and Tax Identification Number: Form 941 - Employer’s Quarterly Federal Tax Return Form 8109 C - FTD Address Change Letter 147-C - EIN Confirmation Notification Form SS-4 - Confirmation Notification
HS 200 - Supporting Documents	Section B - Licensee Information (Page 4): Item 3 – Type of Entity Ensure the selected entity matches the supporting document listed below. Submit the organizational chart if the owner is (a) for profit corporation, (b) general partnership (d) limited liability company, (e) limited liability partnership, (f) limited partnership, or (g) nonprofit. The organizational chart needs to display the licensee Tax ID/EIN, owners, including ownership percentages, all directors, board members, corporate officers, LLC members/managers, and/or partners, administrator, administrator designee, director of patient care services, director of patient care services designee, and medical director or contracted medical director.
HS 200 - Supporting Documents	Section B - Licensee Information (Page 6): Item 6 – Is the Licensee a subsidiary of another organization? Organization(s) must own 100 percent of the licensee to be considered a parent organization. This parent organization will have its own Employer Identification Number (EIN).Submit an attachment for additional entities if there are more than two subsidiaries.
HS 200 - Supporting Documents	Section B - Licensee Information (Page 11): Evidence of Control of Property Submit a signed copy of the Grant Deed, Bill of Sale, Commercial Lease/Rental Agreement, or Sublease between the property ownership/manager and the lessor, lessee, and sub-lessee, and the proposed licensee. Submit a floor plan that coincides with your office space. At minimum should include, entry, exit, hallway, doorway, suite number, conference room, medical record storage area, and identify any other suite numbers located within the same suite.
CMS 855A	Geographical Service Area (Page 24): Multiple Location must be located within the Parent already approved GSA. Submit a list of the parent approved geographical areas (including counties with corresponding cities and zip codes to be served Submit a web-based map for each county being served

Required Documents for a CHOW Only

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

HS 200

Change of Ownership – Supporting Documents

In addition to the forms required for an Initial application listed above submit the documents requested below:

Copy of Purchase Agreement or Operating Transfer Agreement
A letter from the prospective licensee (to CDPH) stating the location where the stored patient medical records will be maintained and affirming the records will be made available to the previous licensee [SQHC, 2003, Section 6.3 (B)(3)(g)]

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