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HEALTH CARE FACILITY LICENSING AND CERTIFICATION​

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Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

For application status requests, please include the following in your email:

  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Number​​​​​​
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Rehabilitation Clinic

Report of Change Application Checklist for Change of Indirect Ownership

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.

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of Indirect Ownership

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
  • Facility name and address
  • Facility ID number (if known)
  • Brief description of request
  • Previous and proposed/new location
  • Contact information (name, title, phone number, and
    email 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, 1.5MB)

Licensure & Certification Application

[Health and Safety Code (HSC) section 1212(a)]

Tip

  • Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions 
Supporting Documents

B.3 – Organizational Chart – Owner Type

[HSC section 1212(a)]

Submit an organizational chart if the owner is a for 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 ID/EIN # and all directors, board members, corporate officers, LLC, members/managers, and/or partners

Note: Submit the HS 215A form for each new individual

  • Parent company of applicant, if applicable, and all the licensed agencies/facilities they are operating - see B.6
Supporting Documents

Indirect Ownership Purchase Agreement

Submit a purchase, merger, transfer, or sales agreement

HS 215A (PDF)

Applicant Individual Information

[Title 42 Code of Federal Regulation (CFR) section 485.56(a)]

[HSC sections 1212(a), 1225(c)(3)]

The form must be completed and signed for the following individual(s):

  • Applicant Organization
    • Owners, directors, board members, corporate officers, LLC members/managers, partners, and/or trustees of the applicant organization and/or Management Company
  • Each individual having a direct or indirect beneficial interest of five percent or more in the applicant organization and/or parent company

Tips

  • 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 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
  • Section F — If answering yes to any question in this section, complete and attach the facility information sheet (section H)

Supporting Documents

Facility Information Sheet

Each individual 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 3 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
  • Type of facility
  • Type of business entity (include EIN Number)
  • Individual’s nature of involvement
  • Individual’s dates of involvement

HS 309 Page 1 (PDF)


Administrative Organization

[HSC section 1212(a)]

Along with the HS 309, the following supporting documents according to organizational type 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​

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