Skip Navigation LinksICF-DD-N-ICF-DD-CN-CHGB-Provider-Checklist

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:

  • Application ID (if applicable)
  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Number​​​

Intermediate Care Facility/Developmentally Disabled-Nursing
ICF/DD-Continuous Nursing

Report of Change Application Checklist for Change of Governing Board

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 Governing Board 

Forms and Supporting Documents​​

​​Additional Instructions

(​​​Each form listed also has instructions on the form)​

​Cover 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.calho​spitalprepare.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

Tip

  • 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 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:

  • 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

HS 215A (PDF)​

Applicant Individual Information 

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

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 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 Articles of Organization​

​Supporting Documents
New Board Member Verification 
Documentation verifying the appointment of new Board Member(s), such as copy of board meeting minutes, appointment letter, resolution etc.

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








​​
Page Last Updated :