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

• 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 

​

• ​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​​​​
  

B.3 – Organizational Chart – Owner Type

[HSC sections 1212, 1225(c)(3)] [Title 42 Code of Federal Regulations (42 CFR) sections 485.56, 485.709]​

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 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 the licensed agencies/facilities it is operating - see B.6
  

Applicant Individual Information

[HSC 1212] [42 CFR sections 455 subpart B, 485.56]

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 

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 sections 1212, 1225(c)(3)] [42 CFR sections 485.56, 485.709]​

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

​Out of State Corporations

[HSC section 1212]

Copy of the Certificate of Qualifications from the CA Secretary of State allowing the applicant to do business in California