Cover Letter

Letter on company letterhead with the following information:

• License number (only applicable for CHOW)
• Facility name and ID number (if known)
• Brief description of request
• 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/post/california-health-alert-network-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 
  

​B.3 - Organizational Chart - Owner Type

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​
  

[22 CCR section 74105 and 74201] and [HSC section 1405]
This form must be completed for the following individuals and include signatures and dates:

• Owners, agency manager, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization
• Each individual having a beneficial interest of exceeding 10 percent or more in the applicant 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 term 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

[22 CCR section 74105(a)(8)] and [HSC section 1405(h)]

Along with the HS 309, depending on organizational type, the following supporting documents 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)
  

Public Agency

Copy of signed Resolution

Schedule of Fees

[22 CCR section 74105(a)(10)] and [HSC section 1405(j)]

• Received a schedule of fees to be charged and collected
• Received a statement of the method by which each fee is to be computed or determined