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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​

Pediatric Day Health and Respite Care​

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)

Checklist and Instructions - P​lease 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

[Health and Safety Code (HSC) section 1763.4]

Letter on company letterhead with the following information:

  • License number
  • Facility name and address
  • Facility ID number (if known)
  • Brief description of request: Indicate the type of service you would like to add. If adding the Transitional Health Care Needs Optional Service Unit, please specify your request for this service here
  • Previous and proposed/new location
  • 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.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

Note: For PDHRCs who opt to provide services to individuals 22 years of age and older, the PDHRC must apply and be approved to operate a Transitional Health Care Needs Optional Service Unit by indicating this service as a request in the cover letter

HS 200 (PDF)

Licensure & Certification Application 

[Health and Safety Code (HSC) section 1760.4(c) and 1762 and Title 22 California Code of Regulations (CCR) 72201]

Tips

  • Page 6, section B, item 6 —This parent company will have its own Employer Identification Number (EIN)

Note: Pursuant to HSC section 1267.9, any city or county may request denial of an initial license if there is an overconcentration of pediatric day health and respite care facilities in the proposed location of the facility. 

​Supporting Documents
A.10 - Construction

[HSC section 1761.2 and 1761.8]

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

[HSC section 1760.4(c) and 22 CCR section 72201]

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 - (FTD Address Change)
  • Form SS-4 - (Confirmation Notification)​

​Supporting Documents

​B.3 - Organizational Chart - Owner Type

[HSC section 1760.4(c), and 22 CCR section 72201]

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 

[HSC section 1760.4(c) and 22 CCR section 72201]

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 

[HSC section 1760.4(c) and 22 CCR 72201 and 72513]
This form must be completed for the following individuals and include signatures and dates:

  • Administrator of the facility
  • Owners, directors, board members, corporate officers, LLC members/managers, and/or partners of the organization
  • Each individual having a beneficial interest of exceeding five percent or more in the 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

[HSC section 1760.4(c) and 22 CCR section 72201]

A resume is required for the Administrator. ​

HS 309 1st Page​ (PDF)


Administrative Organization

[HSC section 1760.4(c) and 22 CCR section 72201]

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) and managers who are not 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

HS 400 (PDF)​


Affidavit Regarding Patient Money

[22 CCR section 72217 and HSC section 1318 and 1760.4(c)]

  • 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

[HSC section 1318 and 1760.4(c) and 22 CCR 72217]

  • 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 California Department Public Health (CDPH) form (not the Department of Social Services form)
  • ​​Licensee name dba Facility name is acceptable​
HS 602 (PDF)

Transfer Agreement

[HSC section 1760.4(c) and 22 CCR 72519]

Copy of current written transfer agreement with a hospital

  • 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 in order to access the RSS portal, therefore program flexes for Initial applications will not be accepted. 

STD 850​​ (PDF)​


Fire Safety Inspection Request (not applicable for a CHOW unless there is construction)

[HSC section 1761.2]

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:

[HSC section 1760.4(c) and 22 CCR section 72201, 72529(a)(10) and 72543(e)]

  • 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 ​
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