āForms and Supporting Documentsāā
| āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
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āCover Letter
| 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.calhoāspitalprepare.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
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āHS 200 (PDF)
| Licensure & Certification Application ICF/DD: Title 22 California Code of Regulations (CCR) section 76225(c) ICF/DD-H: 22 CCR section 76851(a)(2)
Tip - Page 6, section B, item 6 ā An organization will have its own Federal tax ID number
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āSupporting Documents
| āB.3 - Organizational Chart - Owner Type
ICF/DD: 22 CCR section 76205(a)(10)
Submit an organizational chart if the owner is a profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following:
- Applicantās 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 new individual - Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating ā see B.6
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āHS 215A (PDF)ā
| āApplicant Individual Information
ICF/DD: 22 CCR section 76205(a) 5 and 6 and 76225(c) ICF/DD-H: 22 CCR section 76851(a)(2)
This form must be completed for the following individuals: - New directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization
Tips
- Page 2, section B ā 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 ā 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
- āPage 7, section F ā If answering yes to any question in this section, complete and attach the facility information sheet
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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)
- Individualās nature involvement
- Individualās dates of involvement
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HS 309 1st Pageā (PDF)
| Administrative Organization Along with the HS 309, the following supporting documents according to organizational type must be submitted.ā
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Supporting Documentsā
| 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 ā The incorporation date is located in the top right corner of the applicant Articles of Incorporationā
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Supporting Documentsā
| 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
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āSupporting Documents
| āNew Board Member Verification
Documentation verifying the appointment of new Board Member(s), such as copy of board meeting minutes, appointment letter, resolution etc.
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āHS 309 2nd Pageā (PDF)
| Organizational Structure ICF/DD: 22 CCR section 76205
Only complete fields that are applicable to applicantās entity type.
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āSupporting Documents
| Public Agency Copy of signed Resolution
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āSupporting Documents
| Partnershipā Copy of signed Partnership Agreement
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āCDPH 325 (PDF) (For ICF-DD Only)
| Criminal Record Clearance Submissions [HSC section 1575.7]
Submit this form with the names of the individuals in the roles below: - Directors
- Board Members
- Corporate Officers
- LLC Members/Managers
- Partners
Note: For new individuals only
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āāCDPH 322āā (PDF)
(For ICF-DD only)
| Transmittal Application for Criminal Background Investigation Background Investigation [HSC sections 1575.7(a)(1) and 1575.7(a)(2)]
Mail this form to the address indicated on the form only for the new individuals below:ā - Directors
- Board Members
- Corporate Officers
- LLC Members/Managers
- Partners
Submit this form to CDPH Criminal Background Section (address is listed on the form).ā
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āBCIA 8016ā (PDF)
(For ICF-DD only)
| Request for Live Scan [HSC section 1575.7]ā
Mail this form to the address indicated on the form only for the new individuals below: - Directors
- Board Members
- Corporate Officers
- LLC Members/Managers
- Partners
Submit copy if this form to CDPH Criminal Background Section. Centralized Applications Branch may also request a copy of this form.ā
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