HEALTH CARE FACILITY LICENSING AND Certification

Intermediate Care Facility/Developmentally Disabled-Nursing
&
Intermediate Care Facility/Developmentally Disabled-Continuous Nursing

Initial and Change of Ownership Application Checklist

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.

Initial License
Change of Ownership (CHOW)
Medi-Cal

Checklist and Instructions - Please submit your documents in this order

Required Documents for an Initial License or CHOW

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 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://calhospital.org/calhospitalprepare) 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
Supporting Documents	DDS Approved Program Plan Submit a copy of the approved program plan from Department of Developmental Services (DDS)
HS 200 (PDF, 1.5MB)	Licensure & Certification Application Tips: Page 6, section B, item 6 —This parent company will have its own Employer Identification Number (EIN) If applying for Med-Cal, applicant must complete the “Subcontractor Information and Significant Business Transactions” attachment Note: Pursuant to HSC section 1267.9, any city or county may request denial of an initial license if there is an overconcentration of ICF/DD, ICF/DD-H and ICF/DD-N facilities in the proposed location of the facility.
Supporting Documents	A.11 - Construction For Initial, submit one of the following regardless if construction occurred or not: Evidence of Compliance with local building code requirements or; Certificate of Occupancy issued by the local building authority
Supporting Documents	B.2 - IRS Internal Revenue Service Documentation Submit one of the following IRS tax documents showing entity’s legal name and Tax Identification Number: Letter 147-C (EIN Confirmation Notification) Form 941- (Employer’s Quarterly Federal Tax Return) Form 8109-C (Federal Tax Deposit Address Change) Form SS-4 (Confirmation Notification)
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 of these individuals Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating- see B.6
Supporting Documents	D.1 - Control of Property Submit a copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee
HS 215A (PDF)	Applicant Individual Information This form must be completed for the following individuals and include signatures and dates: Administrator of the facility and Administrator Designee Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization and/or Management Company Each individual having a beneficial interest of exceeding 5 percent or more in the applicant organization and/or parent organization Tips: Page 2, section B, Item 3 — 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, must complete section H for the Facility Information Sheet
Supporting Documents	Resume A resume is required for the Administrator. Note: For ICF/DD only, a resume is also required for an Administrator’s Designee.
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 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 List of Managing Members (only if additional space is needed to input all managing members)
HS 309 2nd Page (PDF)	Organizational Structure Only complete fields that are applicable to applicant’s entity type Tip Page 2, item 1 — Health care districts will fill in the circle for other
Supporting Documents	Public Agency Copy of signed Resolution
Supporting Documents	Partnership Copy of signed Partnership Agreement
CDPH 322 (PDF)	Transmittal Application for Criminal Background Investigation Complete the CDPH 322 form for the following individual and mail to the address indicated on the form: Administrator
CDPH 325 (PDF)	Criminal Record Clearance Submissions Submit form for the following individual: Administrator
Supporting Documents	Consultant Letter If a consultant requests to be exempt from having to obtain multiple background checks, a letter signed by the licensee owners or officers must be submitted stating that the following criteria have been met: Is employed as a consultant and acts as direct care staff Is a registered nurse, licensed vocational nurse, physical therapist, occupational therapist, or speech-language pathologist Has obtained a criminal record clearance as a prerequisite to holding a license or certificate to provide direct care services Has a license or certificate to provide direct care services that is in good standing with the appropriate licensing or certification board Is providing time-limited specialized clinical care or services Is not left alone with a client
HS 400 (PDF)	Affidavit Regarding Patient Money Mark either A or B box. If B is checked, enter the amount of patient monies managed and submit the bond required on form HS 402 If handling less than $500 for all patients in any one month, a bond is not required.
HS 402 (PDF)	Surety Bond Verification Is signed by the bonding agency Possesses the embossed or raised seal of the bonding agency A copy of the bond is acceptable and does not have to be an original, however the embossed or raised seal of the bonding agency and Power of Attorney must be visible Form is only required when applicable Tips: Please check the upper right-hand corner of this form to ensure you are submitting the CA Department Public Health form (not the Department of Social Services’ form) Licensee name dba Facility name is acceptable
HS 602 (PDF)	Transfer Agreement Copy of current written transfer agreement. May submit a CDPH 5000 Program Flex if Transfer Agreement cannot be obtained. Tips: The facility administrator may sign this form The facility may not have a provider number yet and this line may be left blank Note: For all other program flex requests the program flex must be submitted online via the Risk & Safely Solutions (RSS) platform. Note: Facility must be currently licensed to access the RSS portal, therefore program flexes for Initial applications will not be accepted.
DHCS 1051 (PDF)	Civil Rights Compliance Review Send directly to Office of Civil Rights – address is on last page of the form
STD 850 (PDF)	Fire Safety Inspection Request (not applicable for a CHOW unless there is construction) The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The OSHPD Fire Life & Safety (FLS) Inspection approval does not replace this form

Required Documents for a CHOW Only

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Supporting Documents

All of the forms required for an “Initial” application listed above in addition to the documents requested below:

Copy of “Purchase Agreement” or “Operating Transfer Agreement”
When applicable, written verification (with amount) by public accountant, accounting for all patient monies transferred to the custody of the new licensee. If none, need statement from current licensee that they did not handle resident monies
When applicable, copy of receipt (with amount) signed by the new licensee in exchange for such monies
A letter from the current and prospective licensee (to CDPH) stating where the stored patient medical records will be maintained, and that the records or copies will be made available to both new and former licensee

Medi-Cal Certification Documents

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
HS 328 (PDF)	Notice - Effective Date of Provider Agreement If applying for both Medi-Cal and Medicare certification, only submit one copy of this form
DHCS 9098 (PDF, 2.9MB)	Medi-Cal Provider Agreement Do not leave any questions blank. Enter “same” or “N/A” if not applicable The mailing address must be the same as reported on the HS 200 form Notarized signature page is required Submit the “Acknowledgement” page from the notary public, if applicable
CMS 3070G (PDF)	Intermediate Care Facility for Persons with Mental Retardation Survey Report This is a “survey” report. The applicant only needs to complete the top portion of the form - the remainder will be completed during the survey