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HEALTH CARE FACILITY LICENSING AND CERTIFICATION​​​

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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​​​​




Skilled Nursing Facility

Report of Change Application Checklist for Change of Stock Transfer

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.

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 Documents for a Stock Transfer Change

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:

  • 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

SNF: Health and Safety Code (HSC) Section 1253.3

Tips

  • Page 6, Section B, item 6 — This parent company will have its own Employer Identification Number (EIN).
Supporting Documents

B.3 – Organizational Chart - Owner Type

SNF: HSC Section 1253.3
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
  • Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating - see B.6
Supporting Documents
Proposed Stock Purchase Agreement

SNF: HSC section 1253.3(c)(14)

Signed agreement by the current and prospective owners that the purchase or sale of the facility is pending and will only occur after receiving approval of 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 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 owners

HS 215A (PDF)

Applicant Individual Information 

SNF: HSC sections 1253.3 and 1267.5
This form must be completed and signed for the following individuals:

  • Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization
  • Each new individual having a beneficial interest of five percent or more in the applicant organization and/or parent organization

Tips

  • 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 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 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
  • Foreign (out-of-state) applicants submit a copy Certificate of Qualification from the California Secretary of State
  • 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
  • Foreign (out-of-state) applicants submit a copy Certificate of Qualification from the California Secretary of State
  • List of Managing Members (only if additional space is needed to input all managing members)

Organizational Structure

Only complete fields that are applicable to applicant's entity type

Supporting Documents

Public Agency

Copy of signed Resolution

Supporting Documents 

Partnership

Copy of signed Partnership Agreement

Final Transaction Documents Required for End Process

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Approval Letter 

Provide your Approval Letter received from the Department of Public Health
Supporting Documents

Stock Purchase Agreement

Submit a copy of the signed finalized Purchase Agreement​

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