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

[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
  

​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
  

[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
  

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:

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
  

Public Agency

Copy of signed Resolution

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.​

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.