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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​​

Referral Agency

​​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

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/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 
HS 200 (PDF)

Licensure & Certification Application 

[Title 22 California Code of Regulation (CCR) section 74101] and [Health and Safety Code (HSC) section 1403]

Tips

  • Page 6, section B, item 6 —This parent company will have its own Employer Identification Number (EIN)
​Supporting Documents
A.10 - Construction
A certificate of occupancy is not required

​Supporting Documents

B.2 - IRS Internal Revenue Service Documentation

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

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 

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 

[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

Supporting Documents​

Resume

A resume is required for the Agency Manager

HS 309 1st Page​ (PDF)


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:

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)

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

Supporting Documents

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
Supporting Documents

Financial Interest Declaration

[22 CCR section 74105(a)(11)] and [HSC section 1405(k)]

  • Received a declaration that neither the licensee nor any member of the partnership or corporation will have any financial interest in any health facility doing business with the referral agency


​​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:

  • Copy of “Purchase Agreement” or “Operating Transfer Agreement”
  • ​A letter from the prospective licensee (to CDPH) stating where the stored patient medical records will be maintained, and that the records will be made available to the previous licensee ​​
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