Cover Letter​

Letter on company letterhead with the following information:

• License number (only applicable for CHOW)
• Facility name and address
• Facility ID number (if known)
• Brief description of request
• 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

A.10 – California Department of Health Care Access and Information (HCAI) [California Building Code Section 1226 and Health and Safety Code (HSC) section 1226] and/or Certificate or Occupancy [22 CCR section 75353]​

One of the two documents are required:

• Written certification: the local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements: 
• California Building Code (CBC)
• California Fire Code (CFC)
• California Electrical Code (CEC)
• California Mechanical Code (CMC)
• California Plumbing Code (CPC)
• California Administrative Code (CAC)
   
• ​​CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by the local building authority

​Note: Title 24 compliance does not apply to CHOWs unless there has been construction and/or remodeling.

If construction occurred and if the construction resulted in a new building or addition:

• Submit a Certificate of Occupancy
• ​This is not applicable if there were alterations or repairs to existing buildings performed or conversion of space
  

​B.3 – Non-Profit Status – Owner Type

[HSC section 1204.1] [22 CCR section 75311(a)(3)]​

Submit a copy of the IRS Tax Exempt Determination Letter showing the non-profit 501(c)(3) status

B.6 – Organizational Chart

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

Applicant Individual Information

[HSC section 1212] [22 CCR sections 75311,75317]

This form must be completed and signed for the following individuals:

• Administrator of the facility
• Applicant Organization
• Directors, board members, corporate officers (Chief Executive Officer, President, Chief Operating Officer, Chief Financial Officer)
• Parent Company (if applicable)
• Directors, board members, corporate officers of the PARENT organization

​​Tips 

• Page 2, section B — 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, complete Section H: Facility Information Sheet
  

​Job Description/ Duties of Administrator

[22 CCR section 75329(b)]​

Submit the job description/duties of the Administrator approved by the Governing Board

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
  

Department of Housing & Community Development (HCD) Insignia

[HSC sections 1765.120 through 1765.155]

• Department of Housing and Community Development (HCD) Approval
• Copy of HCD Inspection Approval, or
• ​Copy of HCD Insignia

Self-Contained Letter

[HSC sections 1765.120 through 1765.155]

• Submit a letter verifying the mobile unit is self-contained
• If the mobile unit is not self-contained, HCAI approval is only required if the utility hookups originate or pass through any general acute care hospital building