āForms and Supporting Documentsā
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āāAdditional Instructions
(āāāEach form
listed also has instructions on the form)ā
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āCover Letterā
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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
- 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:
CAHANā (https://www.calhospitalprepare.org/post/california-health-alert-network-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, 1.5MB)
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Licensure & Certification Application
ICF/DD
and
ICF/DD-H: Health and Safety Code (HSC) section 1265
ICF/DD: Title 22 California Code of Regulations (CCR) section 76201 and 76203(a)(6)
ICF/DD-H: 22 CCR section 76844
Tip
- Page 6, section B, item 6 ā An organization will have its own Federal tax ID number
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āSupporting Documents
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āB.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 profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following:ā
- 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 of these individuals
- āParent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating ā see B.6
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āāSupporting Documents
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āIndirect Ownership Agreement Submit an indirect ownership agreement
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āHS 215A (PDF)ā
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āApplicant Individual Information
ICF/DD: 22 CCR section 76203
ICF/DD-H: 22 CCR section 76844 and 76851(a)(2)
This form must be completed for the following individuals:
- New owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization
- Each new individual having a beneficial interest of exceeding ten percent or more in the applicant organization and/or parent 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
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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 Service. 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 of involvement
- Individualās dates of involvement
- This Sheet must also include any facilities licensed by the California Department of Social Service
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HS 309 1st Pageā (PDF)
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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
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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
- 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
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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
- Page 1, item 3 ā The organization date is located in the top right corner of the applicant Articles of Organizationā
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āHS 309 2nd Pageā (PDF)
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Organizational Structure
ICF/DD: 22 CCR section 76205
Only complete fields that are applicable to applicantās entity type.
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āSupporting Documents
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Public Agencyā
Copy of signed Resolution
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āSupporting Documents
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Partnershipā
Copy of signed Partnership Agreement
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āCDPH 322 (PDF) (For ICF-DD only)
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Transmittal Application for Criminal 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:
- Owners
- Directors
- Board Members
- Corporate Officers
- LLC Members/Managers
- Partners
- Individuals having a beneficial interest exceeding 5% or more in the applicant organization and/or parent organization
Submit this form to CDPH Criminal Background Section (address is listed on the form).
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āBCIA 8016ā (PDF) (For ICF-DD only)ā
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āRequest for Live Scan
[HSC section 1575.7]
Mail this form to the address indicated on the form
only
for
the
new individuals below:
- Owners
- Directors
- Board Members
- Corporate Officers
- LLC Members/Managers
- Partners
- Individuals having a beneficial interest exceeding 5% or more in the applicant organization and/or parent organization
Submit copy if this form to CDPH Criminal Background Section. Centralized Applications Branch may also request a copy of this form.āā
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