Skip Navigation LinksREHABC-CORF-CHGB-Provider-Checklist

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:

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

Rehabilitation Clinic/Comprehensive Outpatient Rehabilitation Facility 

Report of Change Application Checklist for Change of Governing Board

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 Governing Board 

Forms and Supporting Document​s​​​

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
  • 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, 1.5MB)

Licensure & Certification Application

[Health and Safety Code (HSC) section 1212]

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 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
​Supporting Documents 
B.6 Organizational Chart

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

485.709]

If the licensee is a subsidiary of another organization, include an organizational chart

HS 215A (PDF)

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)

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 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​

HS 309 Page 1 (PDF)

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

Supporting Documents

Corporation

[HSC section 1212]

  • Filing Statement from the Secretary of State (only if Articles of Incorporation are not endorsed by the CA Secretary of State)
  • Articles of Incorporation (Endorsed by CA Secretary of State)
  • By-Laws (Stating the size of boards)
  • 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 Page 2 (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

[HSC section 1212]

Copy of signed Partnership Agreement

​Supporting Documents 

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



​​
Page Last Updated :