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HEALTH CARE FACILITY LICENSING AND CERTIFICATION​​​​

Rehabilitation Clinic​

Report of Change Application Checklist for Change of Administrator

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 Administrator

Forms and Supporting​ Documents​​​​

Additional I​nstructions

(Each form listed also has ins​​tructions on the form)

Cover Letter

Cover Lett​er

Letter on company letterhead with the following information:

  • License number

  • Facility name and address

  • Licensee physical address

  • Facility ID number (if known)

  • Brief description of request

  • 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​​​​

HS 215A (PDF)​

Applicant Individual Informa​tion

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

[Health and Safety Code (HSC) sections 1212(a), 1225(c)(3)]

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

  • Administrator of the facility

T​ips:

  • 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 Informa​​tion 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 three years. This sheet must also include any facilities licensed by the California Department of Social Services. 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​

Supporting Documents

Resume

[HSC section 1212(a)]​

A resume is required for the Administrator


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