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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​

Intermediate Care Facility

Report of Change Application Checklist for Change of Indirect Ownership

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 - P​lease submit your documents in this order

Required Documents for a Change of Indirect Ownership

Forms and Supporting Documents​

​​Additional Instructions

(​​​Each form liste​d also has instructions on the form)​

​Cover Lette​​r

Cover Letter

Letter on company letterhead with the following information:

  • License number
  • Facility name and address
  • Facility 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 (https://www.calhospitalprepare.org/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)

Licensure & Certification Application

ICF: 22 CCR sections 73203, 73205 and 73225

Tips

  • ​Page 6, section B, item 6 — An organization will have its own Federal tax ID number​
​Supporting Documents
B.3 - Organizational Chart - Owner Type

Submit a before and after organizational chart if the owner is a for profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following:

  • Applicant’s owners, including ownership percentages, Tax IDs/EINs and all directors, board members, corporate officers, LLC members/managers, and/or partners
    Note: Submit the HS 215A form for each of these individuals
  • Parent company of applicant, if applicable, and all the licensed agencies/facilities they are operating – see B.6
​​Supporting Documents
Indirect Ownership Agreement
Submit a copy of the signed indirect ownership agreement

HS 215A (PDF)​

Applicant Individual Information 

ICF: HSC section 1267.5 and

22 CCR sections 73203 and 73225

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

  • New owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization
  • Each individual having a beneficial interest of exceeding five percent or more in the applicant organization and/or parent organization

Tips

  • Page 2, section B — 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 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 E; however, the resume must contain all required information requested in section E
  • Page 7, section F — If answering yes to any question in this section, complete and attach the facility information sheet

Supporting Documents

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

HS 309 1st Page​ (PDF)


Administrative Organization

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

Supporting Documents​

Corporation

  • Filing Statement from the Secretary of State
  • Articles of Incorporation
  • By-Laws
  • Foreign (out-of-state) applicants submit a copy Certificate of Qualification from the California Secretary of State
  • List of Board of Directors (only if additional space is needed to input all board of directors)

Tip

  • ​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
  • Foreign (out-of-state) applicants submit a copy Certificate of Qualification from the California Secretary of State
  • List of Managing Members (only if additional space is needed to input all managing members) 
Tip
  • Page 1, item 3  The organization date is located in the top right corner of the applicant Articles of Organization

HS 309 2nd Page​ (PDF)


Organizational Structure 

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

​Supporting Documents

Public Agency​

Copy of signed Resolution

​Supporting Documents

Partnership​

Copy of signed Partnership Agreement

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