HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Referral Agency

Report of Change Application Checklist for Change of Agency Manager

The following is a list of forms and supporting documents required for a complete application packet. Failure to include every form or document will delay processing. or lead to denial.

Checklist and Instructions - Please submit your documents in this order and save a copy of all submitted documents for your records.

Required Documents for a Change of Agency Manager

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 (only applicable for CHOW) Facility name Facility ID number (if known) Licensee physical address Brief description of request Include end date of prior person in the role and start date for current person in the role Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address) The Department will use the invoice contact email address to invoice the application fee The Department will use the applicant contact email address to send all application correspondence General Contact Information (name, title, phone number, fax, email address, and alternative contact information) The Department will use this information to contact the facility for day-to-day business Emergency Contact Information (name, phone number, fax, email address, alternate email, 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) All Facility Letter Contact Information (name, phone number, fax, and email address) The Department will use this information to send All Facility Letters Facility Contact (Public Use) Information (phone number, fax, email address, and website address) The Department will use this information to store facility contact information for the public Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) The Department will use this information to correspond with the facility’s Privacy/Compliance Officer regarding medical breach incidents Signature Tip: Search the Cal Health Find database for current staff
HS 215A (PDF)	Applicant Individual Information [Health and Safety Code (HSC) section 1409.3(b)] and [Title 22 California Code of Regulations (CCR) section 74119(b)] Tips: Section A — List facility name and business address. Select facility type and type of application 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 employer name and address, the start and end dates of employment, job title. The applicant may submit a resume in lieu of this section. The resume must contain all required information requested in section E Be sure to include every facility where the applicant is a currently an agency manager Section F — If answering yes to any question in this section, complete and attach the facility information sheet (section H) Applicant Release — Be sure that applicant signs and dates this section, print name and title
HS 215A - Facility Information Sheet (PDF)	Facility Information Sheet The Agency Manager 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 Service. The following must be completed for each facility and/or agency: Facility name Facility address Facility type Individual’s nature and dates of involvement Entity name, type, and Employer Identification Number (EIN)
Supporting Documents	Resume A resume is required for the Agency Manager

Note: Save a copy of all submitted documents for your records.

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