āForms and Supporting Documentsā
| āāAdditional Instructions
(āāāEach form listed also has instructions on the form)āā
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āCover Letter
| Cover Letterā 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 ā
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āHS 200 (PDF, 1.5MB)
| Licensure & Certification Application
SNF: Health and Safety Code (HSC) sections 1253.3 and 1265
Tip - Page 6, Section B, item 6 ā This parent company will have its own Employer Identification Number (EIN).
- If applying for Med-Cal, applicant must complete the āSubcontractor Information and Significant Business Transactions" attachment
Note: - Page 7, Section C, item 3 ā The name of the proposed facility cannot have the word āRehabilitation" in the facility name unless the facility has previously had a rehabilitation service's which were separately surveyed and approved by the Department [Title 22 California Code of Regulations (CCR) Section 72509 (c)]
- Page 10, Section C, item 6 ā Submit evidence that the licensee has sufficient financial resourced to operate the facility for at least 90 Days
- The amount is determined by multiplying: 90 Days x number of beds x Medi-Cal Rate
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āSupporting Documents
| āB.3 - Organizational Chart - Owner Type 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
āāNote: Submit the HS 215A form for each of these individuals
- Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating- see B.6
- If part of a chain, a diagram indicating the relationship between the applicant and the persons or entities that are part of the chain and the name, address, and license number, if applicable, for each person or entity in the diagram. [HSC 1253.39(c)(10)(B)]ā
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āSupporting Documents
| āIRS - 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)
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āSupporting Documents
| āC.1a and E.11 - Management Company Agreement (If applicable) SNF: HSC section 1265 Facilities operated under a management agreement between the licensee and a management company must complete and submit Attachment E-1 (Management Company Information) and submit a copy of the management agreement - The management agreement must state that the licensee is responsible for the skilled nursing facility
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āSupporting Documents
| āD.1 - Control of Property SNF: HSC sections 1253.3(c)(10)(C) and 1265(h)
Submit a copy of the Grant Deed, Bill of Sale, Proposed Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee
- Must include name and address of any persons, organizations, or entities that own the real property on which the facility seeking licensure
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āHS 215A (PDF)ā
| āApplicant Individual Information
SNF: HSC sections 1253.3 and 1265
This form must be completed for the following individuals: - Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization
- Each individual having a beneficial interest of five percent or more in the applicant organization and/or parent organization
Tip - Page 2, Section B ā 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 ā 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 ā If answering yes to any question in this section, complete and attach the facility information sheetā
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āSupporting Documents
| āFacility 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 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 involvementā
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HS 309 1st Pageā (PDF)
| Administrative Organization Along with the HS 309, the following supporting documents according to organizational type must be submitted:
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Supporting Documentsā
| 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 ā 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
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Supporting Documentsā
| Limited Liability Company (LLC) - Filing Statement from the Secretary of State
- Articles of Organization
- LLC Operating Agreement
- List of Managing Members (only if additional space is needed to input all managing members)
Tip - Page 1, item 3 ā 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
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āHS 309 2nd Pageā (PDF)
| Organizational Structure Only complete fields that are applicable to applicant's entity type Tip - Page 2, item 1 ā Health care districts will fill in the circle for otherā
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āSupporting Documents
| Public Agency Copy of signed Resolution
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āSupporting Documents
| Partnership Copy of signed Partnership Agreement
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| Transfer Agreement SNF: HSC section 1760.4 and 22 CCR section 72519
Copy of current written or proposed transfer agreement with a General Acute Care Hospital
Tip - The facility may not have a Facility Provider Number yet, and may be left blank
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āSupporting Documents
| Proposed Purchase or Sale Agreement SNF: HSC section 1253.3(c)(14)
Signed agreement by the current and prospective licensee's that the purchase or sale of the facility is pending and will only occur after receiving approval from the Department. ā
Please ensure the following, but not limited to, information is on the agreement: - Name and address of facility
- Expected date of sale, pursuant to HSC section 1253.3(c)(13)
- Language acknowledging the sale is taking place and will occur after the approval from the Department
- Name and signatures of both the current and prospective licensee's
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