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)

• The Department will use the invoice contact email address to invoice the application fee

• The Department will use the applicant contact email address to send all application correspondence

• ​General Contact Information (name, title, phone number, fax, email address, and alternative contact information)

• ​​​​​The Department will use this information to contact the facility for day-to-day business

• Emergency Contact Information (name, phone number, fax, email address, alternate email, 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)​​

• ​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​​

​B.3 - Organizational Chart – Owner Type

ICF/DD: 22 CCR section 76205(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:​

• 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 of the licensed agencies/facilities they are operating – see B.6

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

• Individual’s nature of involvement

• Individual’s dates of involvement

• Entity name

• ​Type of business entity (include EIN Number)

Stock Purchase Agreement

Submit a copy of the signed Purchase Agreement.

​​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​​
  

Public Agency​

Copy of signed Resolution

​Criminal Record Clearance Submissions

[HSC section 1575.7]

Submit this form with the names of the individuals in the roles 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
  

Note: For new individuals only