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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:

  • Application ID (if applicable)
  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Numberā€‹ā€‹ā€‹ā€‹ā€‹ā€‹
ā€‹

Skilled Nursing Facility and Intermediate Care Facility

Report of Change Application Checklist for Change of Governing Board

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.

Checklist and Instructions - Pā€‹lease submit your documents in this order

Required Documents for a Change of Governing Board 

ā€‹Forms and Supporting Documentsā€‹ā€‹

ā€‹ā€‹Additional Instructions

(ā€‹ā€‹ā€‹Each form listed also has instructions on the form)ā€‹

ā€‹Cover Letterā€‹

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: CAHANā€‹ā€‹ (https://www.calhospitalprepare.org/post/california-health-alert-network-cahanā€‹)
  • 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€‹HS 200 (PDF,1.5MB)

Licensure & Certification Application

SNF: Title 22 of the California Code of Regulations (CCR) section 72211

ICF: 22 CCR section 73205 and 73225

Tips

  • Page 6, section B, item 6 ā€” An organization will have its own Federal tax ID number
ā€‹Supporting Documents
ā€‹B.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:ā€‹

  • Applicantā€™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 new individual
  • ā€‹Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating ā€“ see section B.6

ā€‹HS 215A (PDF)ā€‹

ā€‹Applicant Individual Information 

SNF and ICF: 22 CCR section 72211

ICF: 22 CCR section 73225

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

  • New directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization
ā€‹Tips
  • 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 5, Section E 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 E; however, the resume must contain all required information requested in section E
  • Page 7, Section F ā€” If answering yes to any question in this section, complete and attach the facility information sheet

HS 215A Page 3 (PDF)

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)
  • ā€‹Individualā€™s nature of involvement

HS 309 Page 1 (PDF)


Administrative Organization

Along with the HS 309, the following supporting documents according to organizational type must be submitted.ā€‹

Supporting Documentsā€‹

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)
ā€‹ā€‹Tip
  • ā€‹Page 1, item 3 ā€” The incorporation date is located in the top right corner of the applicant Articles of Incorporationā€‹

Supporting Documentsā€‹


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)
ā€‹Tip
  • Page 1, item 3 ā€” The organization date is located in the top right corner of the Articles of Organization

ā€‹Supporting Documents
ā€‹New Board Member Verification 
Documentation verifying the appointment of new Board Member(s), such as copy of board meeting minutes, appointment letter, resolution etc.ā€‹

ā€‹HS 309 Page 2ā€‹ (PDF)


Organizational Structure 

Only complete fields that are applicable to applicantā€™s entity type

ā€‹Supporting Documents

Public Agency

Copy of signed Resolution

ā€‹Supporting Documents

Partnershipā€‹ā€‹

Copy of signed Partnership Agreementā€‹ā€‹ā€‹

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