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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health



Intermediate Care Facilities for the Developmentally Disabled: Initial Licensure or Change of Ownership
Applicant Checklist  ​(ICF/DD, ICF/DD-H, and ICF/DD-N)

The following is a quick reference of some of the questions found on the required forms. It includes the form number, name of form, and an explanation of specific requirements and/or attachments needed for specific forms. This is not an all-inclusive list of the questions that need to be answered so read the questions and instructions on each form.

Note: All forms listed are in PDF format.

Form #​Item #​Description​Check List
HS 200 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​Licensing & Certification Application (H&S Code Sections 1339.41)
Note: Please read the instructions on the HS 200 form prior to completion of the form. The items listed below are the most common items that are not completed correctly – however, these are not all of the items listed on each form.

 

​B.1​Licensee’s name
  • The licensee’s formal organization name must be consistent throughout all documents.
​​B.3.

​​Owner Type (Title 22 CCR Sections 76205(a)(10), 76225, and 76851)

Submit an organization chart/flow chart if the owner is a profit or nonprofit corporation, limited liability company (LLC), or general partnership. The organization chart needs to display the following:

  • Applicant’s owners, directors, board members, corporate officers, LLC members/managers, and 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.
​B.5.a.​Licensee’s "other" facility involvement
  • Answer all aspects of the question.
​​B.5.b.​Revocation, suspension, etc. action
  • If applicable to the licensee, submit the information requested.
​​B.6.​Subsidiary (Parent Company) Information

If there is a “subsidiary” (parent company) submit:

  • An organization chart with the parent company name.
  • A listing of all owners, directors, board members, corporate officers, LLC members/managers, and partners of the parent company.
    Note: Submit the HS 215A form for each of these individuals
  • A listing of all facilities the parent company is operating.
​​C.1.b​"Interim" Management Company Agreement
  • Note if CHOW: If there is an "interim" Management Company Agreement, between the current and the prospective licensee, submit a signed and dated copy of Agreement.
​​C.2.​Name of "Proposed" and "Current" Agency
  • Enter both facility names if this is a CHOW.
​​C.6.a

Administrator 

Administrator must:

  • Be a licensed Nursing Home Administrator or QMRP [Title 22 CCR Section 76513(a) and H&S Code Sections 1276.5(d) & 1276.5(d)(1)].
    Note: Submit the HS 215A form for the administrator.

  • Obtain fingerprint clearance if the administrator responsible for more than one facility (Title 22 CCR Sections 76513(a) and H&S Code Section 1265.5).
​​C.7.​Ownership
  • List all individuals having 5% or more ownership, unless "nonprofit."
  • Submit the HS 215A form for each of these individuals. 
​C.9.

​Over-concentration

  • Zoning approval letter that is required for all "initial" applications. The appropriate district office (DO) will handle this letter.
​Done by DO
​C.10.

​Program Plan (Title 22 CCR Sections 76305 and 76856)

  • Submit a copy of the Program Plan approval letter.
  • Submit a letter to CDPH from the "current" licensee, if this is a CHOW, that the "proposed" licensee has their permission to use the current licensee’s Program Plan for up to 6 months.
  • Note if CHOW: If you are using the current licensee’s Program Plan, submit proof that you have submitted your Program Plan to the Department of Development Services.
​D.1.
D.2.
​Property Ownership
  • 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.
​​F.1.​Signature [Title 22 CCR section 76205(a)(1)]
  • Original "signature" is required and must be signed by the applicant (not the administrator unless the owner is the administrator).
HS 215A​ ​ ​ ​​ ​ ​ ​ ​ ​

​Applicant Individual Information (Title 22 CCR Sections 76205(a)(6) to (a)(7), & 76225)
Note: Please read the instructions on the HS 215A form prior to completion of the form. This form must be completed for the following individuals with original signatures:

  • Administrator of the facility
  • Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant and parent organization.
  • Each individual having a beneficial interest of 5% or more in the applicant organization and/or parent organization[H&S Code Section 1267.5(a)(1)].
​​Sign​Signature
  • Original "signature" is required.
​​Fac Info Sheet​​Facility Information Sheet
If applicable, each individual must complete and submit the “Facility Information Sheet” for each facility and/or agency with which they have a current or past relationship within the last 3 years. The following must be completed for each facility and/or agency:
  • Facility name and address
  • Type of facility
  • Type of business entity (include EIN Number)
  • Individual’s nature and dates of involvement
  • This sheet must also include any facilities licensed by the California Department of Social Services (Title 22 CCR Section 76205(a)(6).
HS 309 1st page ​ ​ ​ ​​​ ​Administrative Organization ​
​2.​Administrator of Corporation or LLC – This is usually the CEO/President.
​3. - 7.​Corporations need to submit:
  • Copy of the Filing Statement from CA Secretary of State (only required if Articles of Incorporation are not endorsed by the CA Secretary of State).
  • Copy of all Articles of Incorporation (endorsed by CA Secretary of State).
  • Copy of By-Laws.
  • List of board of directors – submit the HS 215A form for each individual listed under this item.

LLCs need to submit:

  • Copy of the Filing Statement from CA Secretary of State (only required if Articles of Organization are not endorsed by the CA Secretary of State).
  • Copy of all Articles of Organization (endorsed by CA Secretary of State).
  • Copy of Operating Agreement.
  • List of members/holders/officers/managers – submit the HS 215A form for each individual listed under this item.
​9.​Governing Board of Directors
  • Enter the number of board members or members/managers.
  • Submit the HS 215A form for each individual listed under this item.
​10.​Board Officers and/or LLC Members/Managers
  • Submit the HS 215A form for each individual listed under this item.
HS 309
2nd page ​ ​ ​ ​
​Organizational Structure ​
​1.​California Out-of-State Corporations, LLC, etc.
  • Submit a copy of the Certificate of Qualification from the California Secretary of State.
​3. & 4.​Public Agency
  • Submit a copy of the signed Resolution.
​5.​​Corporations, LLCs, and Partnerships need to complete. N/A for nonprofit.
​Bottom of page​​Partnerships need to submit:
  • A copy of the Partnership Agreement
  • Copy of the California Secretary of State filing, if applicable.
  • HS 215A form for each individual listed under this item.
​HS 322

​Transmittal Application for Criminal Background Investigation

  • Submit for the administrator, manager, licensee (applicant), and all personnel of the facility including employees and direct care staff (Title 22 CCR Sections 76209(a), 76513(b), and 75845 and H&S Code Section 1265.5).
  • Submit for owners, board officers, directors and partners, if this is an ICF/DD "only" facility (Title 22 CCR Section 76209).
  • Submit for administrator’s designee if this is an ICF/DD "only" facility and the administrator is responsible for more than one facility [Title 22 CCR Section 76513(a) and H&S Code Section 1276.5(d)(1)].
  • Submit this form to the address indicated on the form – this form is not returned to CAB.
CDPH 325

​Criminal Record Clearance Submissions (H&S Code Section 1265.5)

  • Refer to the instructions on the form.
  • Submit for the administrator, manager, licensee (applicant), and all personnel of the facility including employees and direct care staff (Title 22, Section76209(a), 76513(b), & 75845 and H&S Code Section1265.5).
  • Submit for owners, board officers, directors and partners, if this is an ICF/DD "only" facility (Title 22 CCR Section 76209).
  • Submit for administrator’s designee if this is an ICF/DD "only" facility and the administrator is responsible for more than one facility [Title 22 CCR Section 76513(a) and H&S Code Section 1276.5(d)(1)].
​BCIA 8016

​Request for Live Scan Service

  • Note: For out-of-state fingerprint clearance, contact CAB at (916) 552-8630 or by e-mail at: CAB@cdph.ca.gov.
  • Instructions for completion of the BCIA 8016 form are available on the Attorney General’s website. Refer to the "sample" BCIA 8016 form on the L&C "Applications for an Intermediate Care Facility for the Developmentally Disabled" website.
  • The "OR#" must be A1226.
  • Submit for the administrator, manager, licensee (applicant), and all personnel of the facility including employees and direct care staff [Title 22, Section 76209(a), 76513(b), & 75845 and H&S Code Section 1265.5].
  • Submit for owners, board officers, directors and partners, if this is an ICF/DD "only" facility (Title 22 CCR Section 76209).
  • Submit for administrator’s designee if this is an ICF/DD "only" facility and the administrator is responsible for more than one facility [Title 22 CCR Section 76513(a) and H&S Code Section 1276.5(d)(1)].
  • This form is not returned to CAB.
​Cons Ltr

​Consultant Letter [H&S Code Section 1265.5(h)]

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

​Affidavit Regarding Patient Money (Title 22 CCR Section 76241 and 76852.2)

  •  Be sure to mark either A or B box. If B is checked, enter the amount of money to be handled and submit the bond required on form HS 402.
HS 402

​Surety Bond Verification (Title 22 CCR Section 76241 and 76852.2)

  • Be sure the HS 402 form is a CDPH form.
  • Is signed by the bonding agency.
  • Possesses the embossed seal of the bonding agency.
  • Submit an "original" bond or an "embossed" Power of Attorney.
HS 602

​Transfer Agreement Between (Title 22 CCR Sections 76505 and 76909)

  • The Transfer Agreement needs to be current (within one year). Please submit a copy of the Transfer Agreement.
​DHCS 1051

​Civil Rights Compliance Review

  •  Send directly to Office of Civil Rights – address is on last page of the form.
​​CHOW

​Change of Ownership (CHOW) [Title 22 CCR Sections 76203(a)(3) and 76844(a)(2)]

Submit the following:

  • All of the forms required for an "initial" application listed above.
  • Copy of "Purchase Agreement" or "Operating Transfer Agreement."
  • Written verification (with amount) by a public accountant, accounting for all patient monies being transferred to the custody of the new licensee. If none, need statement from the current licensee that they didn’t handle resident monies [Title 22, Section 76569(a)(10)].
  • Copy of receipt (with amount) signed by the new licensee in exchange for such monies [Title 22 CCR Section 76569(a)(11)].
  • A letter from the prospective licensee to CDPH stating where the stored patient medical records will be maintained, and that the records will be made available to the previous licensee [Title 22 CCR Section 76557(f)].



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