HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Skilled Nursing Facility

Management Company Initial 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 and may result in denial of the application.

Note: If the application is approved by CAB, see the section titled Final Transaction Documents Required for End Process. Refer to Health and Safety Code section 1253.3(i) for timeline requirements on the submission of the Final Transaction Documents.

Checklist and Instructions - Please submit your documents in this order

Required Preliminary Documents for Management Company

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
Cover Letter	Cover Letter Letter on company letterhead with the following information: 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
HS 200 (PDF, 1.5MB)	Licensure & Certification Application [Health & Safety Code (HSC), sections 1253.3, 1265.3 and 1267.5] A.1.E - Management Company Complete A.1.E for a management company C.1.A - Management Company Complete C.1.A and submit attachment E-1 Signature Signature is required and must be signed by the Management Company representative (Not the facility Administrator)
Supporting Documents	B.3 – Organizational Chart - Owner Type [HSC sections 1253.3 and 1265] Submit an organizational chart if the management company owner is a for profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following: Management Company’s owners, including ownership percentages, Tax ID/EIN # 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	E. & Attachment E.1.- Management Company Information SNF: HSC section 1253.3(c)(10)(E) Skilled Nursing Facility management company applicants must complete this Attachment Signed agreement by the current licensee and prospective management company that the management of the facility is pending and will only occur after receiving approval from the Department. Please ensure the following, but not limited to, information is on the agreement: Name and address of facility and licensee Expected date of change of management company, pursuant to HSC section 1253.3(c)(13) Language acknowledging the change of management is taking place and will occur after the approval from the Department Name and signatures of both the current licensee and prospective management company
Supporting Documents	IRS - Internal Revenue Service Documentation Submit one of the following IRS tax documents showing the entity’s legal name and Tax Identification Number: Form 941 (Employer’s Quarterly Federal Tax Return) Form 8109-C (FTD Address Chang) Letter 147-C (EIN Confirmation Notification) Form SS-4 (Confirmation Notification)
HS 215A (PDF)	Applicant Individual Information [HSC sections 1253.3, 1265.3 and 1267.5] This form must be completed for the following individuals and include original signatures: Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant Management Company Each individual having a beneficial interest of five percent in the Management Company organization Tip: Page 2, section A — 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 4, section D – 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 D; however, the resume must contain all required information requested in section D Page 5, section E – If answering yes to any question in this section, complete and attach the facility information sheet
Supporting Documents	Facility Information Sheet Each individual that answered yes to any question on Page 5, Section E of the HS 215A, 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 five years. This Sheet must also include any facilities licensed by the California Department of Social Service. 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 1st Page (PDF)	Administrative Organization Along with the HS 309, the following supporting documents according to organizational type must be submitted:
Supporting Documents	Corporation Filing Statement from the Secretary of State Articles of Incorporation By-Laws 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 In addition to this page, corporations are required to complete Item 5 on page 2
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) Tip: Page 1, item 3 — The incorporation date is located in the top right corner of the Articles of Organization Ensure the operating agreement identifies the Capital Contributions, which lists each individual and/or entity that is contributing to the LLC
HS 309 2nd Page (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 Copy of signed Partnership Agreement