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
  

• 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​​​​​​
  

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:

1. Written certification: 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 the 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
  

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)

​B.3 – Organizational Chart – Owner Type

[HSC section 1212(a)] [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
  

B.6 – Organizational Chart

[HSC section 1212(a)] [42 CFR section 485.56]

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

​Bed or Service Request

[HSC section 1204(b)(3)]​

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

​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
  

Professional Licenses/Certificates

[HSC section 1212(a)(6)]

• An active registered medical license is required for the Medical Director

• Provide a printout of the current license from the Department of Consumer Affairs
  

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
  

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
  

​Partnership

[HSC section 1212(a)]

Copy of signed Partnership Agreement

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
  

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
  

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