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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 address Facility 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) - The Department will use this information to send All Facility Letters
Facility Contact (Public Use) Information (phone number, fax, email address, and website address) - The Department will use this information to store facility contact information for the public
Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) - The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents
Signature
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HS 200 (PDF, 1.5MB)
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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 — An organization will have its own Federal tax ID number
Signature must be from the applicant (Licensee/owner), not the Administrator, unless the owner is the Administrator.
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Supporting Documents
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B.3 - Organizational Chart - Owner Type ICF/DD: 22 CCR section 76205(a)(10) 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 new individual
- Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating – see B.6
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HS 215A (PDF)
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Applicant 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 — 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
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Supporting Documents
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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 involvement Individual’s dates of involvement
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HS 309 1st Page (PDF)
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Administrative Organization
Along with the HS 309, the following supporting documents according to organizational type must be submitted.
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Supporting Documents
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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:
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Supporting Documents
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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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Supporting Documents
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New 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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HS 309 2nd Page (PDF)
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Organizational Structure
ICF/DD: 22 CCR section 76205
Only complete fields that are applicable to applicant’s entity type.
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Supporting Documents
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Public Agency
Copy of signed Resolution
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Supporting Documents
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Partnership
Copy of signed Partnership Agreement
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CDPH 325 (PDF) (For ICF-DD Only)
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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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CDPH 322 (PDF) (For ICF-DD only)
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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:
Directors Board Members Corporate Officers LLC Members/Managers Partners
Submit this form to CDPH Criminal Background Section (address is listed on the form).
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(For ICF-DD only)
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Request for Live Scan [HSC section 1575.7]
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.
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