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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 Clinics and Comprehensive Outpatient Rehabilitation Facility 

Initial and Change of Ownership Application Checklist 

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.

  • Initial License
  • Change of Ownership (CHOW)
  • Medi-Cal
  • Medicare

Checklist and Instructions - P​lease submit your documents in this order

Required Documents for an Initial Licensure or CHOW 

Forms and Supporting​​​​​ Docume​​nts​​

​​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 (only applicable for CHOW)
  • 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)

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

A.10 – California Department of Health Care Access and Information (HCAI) [California Building Code section 1226 and HSC section 1226] and/or Certificate of Occupancy

One of the two documents are required:

  • ​​Written certification: a California licensed architect or the local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements:

    • California Building Code (CBC)
    • California Fire Code (CFC)
    • California Electrical Code (CEC)
    • California Mechanical Code (CMC)
    • California Plumbing Code (CPC)
    • California Administrative Code (CAC) 
  • CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by a California licensed architect or local building authority

Note: Title 24 compliance does not apply to CHOWs unless there has been construction and/or remodeling.

If the facility is newly constructed or a remodeled building, submit the following:

  • Submit a Certificate of Occupancy
  • This is not applicable if there were alterations or repairs to existing buildings performed or conversion of space
​Supporting Documents

Floor Plan​

Submit a floor plan that describes the requested change of service including a schematic of each room

Supporting Documents

B.3 – Internal Revenue Service Documentation

[HSC section 1212(a)]

Submit one of the following IRS tax documents showing entity's legal name and Tax Identification Number:

  • Form 941- (Employer's Quarterly Federal Tax Return)
  • Form 8109- C (FTD Address Change)
  • Letter 147-C (EIN Confirmation Notification)
  • Form SS-4 (Confirmation Notification)
​Supporting Documents

B.3  Non-Profit Status – Owner Type

[HSC section 1212(a)]​

Submit a copy of the IRS Tax Exempt Determination Letter showing the non-profit 501(c)(3) status. (If Applicable)

​Supporting Documents
B.3  Organizational Chart – Owner Type

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

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 of the licensed agencies/facilities it is operating- see B.6
​Supporting Documents

B.4.b  License Revocation (if applicable)

[HSC section 1212(a)]

Submit additional information, including all ownership and facility information, date and any final action

​Supporting Documents

B.6  Organizational Chart

[42 CFR section 485.56]

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

Supporting Documents

D.1 – Control of Property​

[HSC section 1212(a)]​

Submit a copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed Licensee

​CDPH 609 (PDF)
Bed or Service Request

[HSC section 1204(b)(3)]​

Complete facility information and check the rehabilitation services the facility is requesting to provide

HS 215A (PDF)​

Applicant Individual Information

[HSC section 1212(a)] [42 CFR sections 455 Subpart B and 485.56]

This form must be completed and signed for the following individuals:

  • Administrator of the facility
  • Medical Director
  • Owners, directors, board members, corporate officers, LLC members/managers, and partners of the parent, grandparent, great grandparent, and etc. organization, if applicable
    Note: Corporate officers as defined in the By-Laws
  • Each individual having a beneficial interest of exceeding five percent or more in the applicant organization and/or parent, grandparent, great grandparent, and etc. organization
Tips

  • Page 2, section B — The date of birth is an identifier, as several people may have the same name. This will ensure that each individual is associated with the correct facility or entity
  • Page 5, 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
  • Page 7, section F — If answering yes to any question in this section, complete Section H: Facility Information Sheet
​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
​Supporting Documents

Resume

[HSC sections 1212(a), and (a)(6)]

A resume is required for the Administrator, and Medical Director

​Supporting Documents

Professional Licenses/ Certificates

[HSC section 1212(a)(6)]

HS 309 1st Page​ (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

[HSC section 1212(a)]

  • 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)

[HSC section 1212(a)]

  • 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

[HSC section 1212(a)]

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

[HSC section 1212(a)]

Copy of signed Resolution

​Supporting Documents ​​

Partnership

[HSC section 1212(a)]

Copy of signed Partnership Agreement

Supporting Documents​
Out of State Corporations

[HSC section 1212(a)]

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

STD 850 (PDF)

Fire Safety Inspection Request

[42 CFR section 485.62(a)(1)]

The STD 850 form is required. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form.

  • This form is not required for a CHOW unless there has been construction and/or remodeling.
  • The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form.
  • ​If the STD 850 form is NOT required for a particular MOBILE clinic, a written statement from the local fire authority agency must be submitted



Required Documents for Mobile Clinics Only

Forms and Supporting Documents​​​

Additional Instructions

(Each form listed also has instructions on the form) ​

Housing & Community Development (HCD)
Insignia



Department of Housing & Community Development (HCD) Insignia

[HSC section 1765.120(b)]

  • Department of Housing and Community Development (HCD) Approval
    • Copy of HCD Inspection Approval, or
    • Copy of HCD Insignia
Vehicle Registration 

Copy of Vehicle Registration

[HSC section 1765.120(a)]

Submit copy of DMV registration documents, indicating:

  • Vehicle Identification Number (VIN)
  • Type of vehicle
  • Manufacturer
Self-Contained Letter

Self-Contained Letter

[HSC section 1765.150(b)]

  • Submit a letter or statement on cover letter verifying the mobile unit is self-contained
  • If the mobile unit is not self-contained, HCAI approval is only required if the utility hookups originate or pass through any general acute care hospital building
​Local Planning/Zoning Approval

Local Planning / Zoning Approval

[HSC section 1765.155(a)]

  • Submit a copy of the Local Planning/Zoning approval
  • If the Local Planning/Zoning approval is not required for a particular mobile clinic, CAB needs a written statement from the Local Planning/Zoning agency



​​Required Documents for a CHOW Only​

Forms and Supporting Documents​​​

Additional Instructions

(Each form listed also has instructions on the form) ​

Supporting Docum​​ents

In addition to the forms required for an Initial application listed above submit the documents requested below: [HSC section 1212(a)]

  • Copy of Purchase Agreement or Operating Transfer Agreement
  • Interim Management Agreement (If applicable)
  • A letter from the prospective licensee (to CDPH) stating where the stored patient medical records will be maintained, and that the records will be made available to the previous licensee



Medi-Cal Certification Documents 

Forms and Supporting Documents​​​

Additional Instructions

(Each form listed also has instructions on the form) ​

HS 328 (PDF) ​​

Notice – Effective Date of Provider Agreement

Submit one copy of the HS 328 form with original signature

DHCS 9098 (PDF)  

Medi-Cal Provider Agreement

  • Do not leave any questions blank. Enter “same" or “N/A" if not applicable
  • The mailing address must be the same as reported for the consolidated clinic on cover letter
  • Notarized signature page is required
  • Submit the "Acknowledgement" page from the notary public, if applicable

​​


Medicare Certification Documents 

Forms and Supporting Documents​​​

Additional Instructions

(Each form listed also has instructions on the form) ​

CMS 1561 (PDF)

Notice – Effective Date of Provider Agreement

Submit one copy of the HS 328 form with original signature

CMS 855B (PDF)

Medi-Cal Provider Agreement

  • Do not leave any questions blank. Enter “same" or “N/A" if not applicable
  • The mailing address must be the same as reported for the consolidated clinic on cover letter
  • Notarized signature page is required
  • Submit the "Acknowledgement" page from the notary public, if applicable
HHS 690 (PDF) 


Assurance of Compliance​

CMS 359 ​(PDF) 

Comprehensive Outpatient Rehab Facility Report

Submit the comprehensive outpatient rehab facility report for certifications




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