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 
  

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
  

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)
  

Administrative Organization

[HSC section 1212(a)]

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