Skip Navigation LinksOPT-SP-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:

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

Outpatient Physical Therapy/Speech-Language Pathology Provider

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 - Please 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
    email 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.calhospitalprepare.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, 1.5MB)

Licensure & Certification Application

[Title 42 Code of Federal Regulations (42 CFR) section 485.709]

Tip

  • Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions 
Supporting Documents

B.3 – Organizational Chart – Owner Type

[42 CFR section 485.709(a)]

Submit an organizational chart if the owner is a for 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 the licensed agencies/facilities it is operating - see B.6
Supporting Documents 

B.6 – Organizational Chart

[42 CFR section 485.709(a)]

If licensee is a subsidiary of another organization, an organizational chart must be submitted

HS 215A (PDF)

Applicant Individual Information
[42 CFR sections 455.101, 455.104, 485.709(a)]

The form must be completed and signed for the following individual(s):

  • Applicant Organization
    • Owners, directors, board members, corporate officers, LLC members/managers, partners, and/or trustees of the applicant organization and/or Management Company

Tips

  • Section B – List applicant's legal name, nature of involvement to the facility, date of birth, driver's license or state-issued identification number and expiration date, social security number
  • 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
  • Section F — If answering yes to any question in this section, complete and attach the facility information sheet (section H)

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 of involvement
  • Individual's dates of involvement

HS 309 Page 1 (PDF)

Administrative Organization

[42 CFR section 485.709(a)]

  • Corporations complete page one
  • Do not submit any attachments

HS 309 Page 2 (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
Page Last Updated :