āForms and Supporting Documentsāā
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āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
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āCover 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
- 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
Tip
- Page 6, section B, item 6 ā An organization will have its own Federal tax IDā number
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āSupporting Documents
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āB.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:
- 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 individualā
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āHS 215A (PDF)ā
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āApplicant 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 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 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)
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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
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āSupporting Documents
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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)
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Organizational Structure
Only complete fields that are applicable to applicantās entity type.
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āSupporting Documents
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Public Agency
Copy of signed Resolution
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āSupporting Documents
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Partnershipā
Copy of signed Partnership Agreement
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