|Form #||Item #||Description||Check List|
|HS 200 |||
Licensure & Certification Application
- Note: Please read the instructions on the HS 200 form prior to completion of the form.
- The items listed below are the most common items that are not completed correctly – however, these are not all of the items listed on each form.
Construction (Title 22 Section 72205)
- N/A for CHOWS, unless there has been construction and/or remodeling.
- If this is a newly constructed and/or remodeled building, or if this is not a previously licensed facility (i.e., existing building with no construction or remodeling required)applicant needs to contact the Office of Statewide Health Planning & Development (OSHPD) at the following website for Title 24 clearance:
(Title 22 CCR 72601 & 73601)
|OSHPD sends directly to DO |
Licensee’s name [Title 22 Sections 72509(c) & 73205(a)(1)]
- The licensee’s formal organization name must be consistent throughout all documents.
- This question must be answered.
- If nonprofit, submit a copy of Internal Revenue Service letter of determination status for this entity.
- Submit an organization/ flow chart for this organization that displays the following (N/A for Sole Proprietorship):[(Title 22 Section 73205(a)(9)]
- Licensee name & tax ID number.
- A listing of the licensee’s owners. "Ownership" is N/A for non-profit.
Licensee’s "Other" Facility Involvement.
- Answer all aspects of the question to identify other facilities, agencies, or clinics the licensee has been involved with.
Revocation, Suspension, etc. Action.
- If applicable to the licensee, submit the information requested.
Subsidiary (Parent Company) Information
If there is a "subsidiary" (parent company) submit:
- An organization chart with the parent company name.
- A listing of all owners (of the parent company) and their ownership percentages, directors, board members, corporate officers, LLC members/managers, and partners of the parent company. [H&S Section 1265(i)]
- A listing of all facilities the parent company is operating.
Management Company (H&S Sections 1265, 1267.5, 1575.1)
- Applicant needs to indicate "yes" or "no" if the facility is operated under a Management Agreement between the licensee and a management company. If the answer is "yes" and the facility is an ADHC, GACH, ICF or SNF, you need to submit Item E-1 below.
"Interim" Management Company Agreement
- Note if CHOW: If there is an "interim" Management Company Agreement, between the current and the prospective licensee, submit a signed and dated copy of Agreement. The agreement must state that the licensee still maintains control of the property and is still financially responsible for the facility.
Name of "Proposed" and "Current" Facility
- Enter both facility names if this is a CHOW.
- For a CHOW, the name of the "proposed" facility cannot have rehabilitation in the facility name unless the facility has previously had rehabilitation services which were separately approved by the Department unless the facility is applying for certification. If not, you must apply for a separate survey for the rehabilitation services to be approved after the CHOW application package has been processed.
- For an "initial" application the applicant must apply for a separate survey for the rehabilitation services to be approved after the "initial" application package has been processed. [Title 22 Section 72509(c)]
- SNF & ICF: Insert Administrator’s name and requested information.
Director of Nursing
- SNF "only" --Insert DON name and requested information.
- List all individuals having 5% or more ownership, unless "nonprofit."
- Submit the organizational chart listing all owners & their percentages.
- Submit evidence that the licensee has sufficient financial resources to operate the facility for at least 45 days. [H&S Section 1265(g)]
- The evidence should be in the form of a bank statement, certificate of deposit, letter of credit, etc. in the name of the licensee.
- The amount is determined by multiplying: 45 days x number of beds x Medi-Cal facility rate.
|D.1. & D.2.|
Property ownership [H&S Section 1265(h)]
- Submit a copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee.
Management Company (H&S Sections 1265, 1267.5, and 1575.1)
- Is this facility an ADHC, GACH, ICF or SNF? Is this facility is operated under a Management agreement between the licensee and a management company? If "yes" submit Item E-1 below.
Management Company Information
- Submit Attachment E-1 (Management Company Information) form. This form will capture the owners, ownership percentages, plus other facilities/agencies that the management Company may own, lease manage, or operate. These management companies have to initially be approved by the Centralized Applications Branch.
- Submit a copy of the Management Agreement, which must state the current licensee still has responsibility for the facility.
- "Original" signature is required and must be signed by the applicant (not the Administrator unless the owner is the Administrator).
|HS 215A |||
Applicant Individual Information.
[H&S 1265(i) & 1267.5 & Title 22 73205 for ICF "only"]
- Note: Please read the instructions on the HS 215A form prior to completion of the form.
- This form must be completed for the following individuals with original signatures:
- Administrator of the Facility.
Director of Nursing -SNF "only" (Title 22 CCR Sections 72327)
- HS 215A form for the Administrator. [Title 22 CCR Sections 72211(b), 72513, & 73205(a)(4)]
- "Resume" for the Administrator.
- Administrator is required to be a licensed Nursing Home Administrator. (Title 22 CCR Sections 73205(a)(4) & 73511(a) & Title 42 CFR 483.75)
The Nursing Home Administrator website.
- SNF "only" --HS 215A form for Director of Nursing
- SNF "only" --copy of professional License.
- SNF "only" --resume.
- HS 215A form for each individual having a beneficial interest of 5% or more in the applicant organization(list their percentages).
- HS 215A form for directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization.
- HS 215A form for each individual having a beneficial interest of 5% or more in the parent company (list their percentages).
- HS 215A form for directors, board members, corporate officers, LLC members/managers, and partners of the parent company.
- HS 215A form for each individual having a beneficial interest of 5% or more in the management company(list their percentages).
HS 215A form for directors, board members, corporate officers, LLC members/managers, and partners of the management company.
- A resume or attachment will be acceptable in lieu of Section "D" being filled out.
Original "signature" is required on all the HS 215A forms.
|Fac Info Sheet|
Facility Information Sheet.
- If you answer "yes" in Section E above, you must complete the Facility Information Sheet which needs to be completed for each HS 215A form submitted (except for the Administrator, unless they are the owner).
- The Facility Information Sheet must include facilities licensed by CA Department of Social Services.
- An attachment may be submitted in lieu of the Facility Information Sheet, if all applicable information is on the attachment.
- If applicable, each individual must complete and submit "Facility Information Sheet" for each facility and/or agency with which they have a current or past relationship within the last 3 years. The following must be completed for each facility and/or agency:
- Facility name and address.
- Type of facility
- Type of business entity (include EIN Number)
- Individual’s nature and dates of involvement
- This Sheet must also include any facilities licensed bythe California Department of Social Services.
|HS 309 1st page ||||Administrative Organization|||
This form is N/A for a sole proprietor.
- Administrator of Corporation or LLC – This is usually the CEO/President.
|3. thru 7.|
Corporations need to submit:
- Copy of the Filing Statement from CA Secretary of State(only required if Articles of Incorporation are not endorsed by the CA Secretary of State).
- Copy of all Articles of Incorporation (endorsed by CA Secretary of State).
- Copy of By-Laws.
LLCs need to submit:
- Copy of the Filing Statement from CA Secretary of State(only required if Articles of Organization are not endorsed by the CA Secretary of State).
- Copy of all Articles of Organization (endorsed by CA Secretary of State).
- Copy of Operating Agreement.
Governing Board of Directors
- Enter the number of members/managers.
- Submit a list of the board of directors or the LLC members/holders.
- Enter the names of the board officers or the LLC officers/managers.
|HS 309 2nd Page ||||Organizational Structure|||
California Out-of-State Corporations, LLC, etc.
- Submit a copy of the Certificate of Qualification from the California Secretary of State.
|3. & 4.|
- Submit a copy of the signed Resolution.
- Corporations and Partnerships need to complete. N/A for nonprofit.
|Bottom of page|
Partnerships need to submit:
- A copy of the Partnership Agreement
- Copy of the California Secretary of State filing
Affidavit Regarding Patient Money (Title 22 CCR Sections 72217 and 73241)
- Be sure to mark either A or B box. Even though the form allows the applicant to indicate that they will not handle any money – this is not an option if the GACH or SNF want to be "certified". They have to obtain a BOND for at least $1,000.00. Enter amount of money to be handled and submit bond required on form HS 402 form. [Centers for Medicare & Medicaid Services, HHS, Section483.10(c)(7)]
Surety Bond Verification (Title 22 CCR Sections 72217 and 73241)
- Be sure the HS 402 form is a California Department of Public Health form
- Is signed by the Bonding agency
- Possesses the embossed seal of the Bonding Agency
- Submit an "original" bond or an "embossed" Power of Attorney
Transfer Agreement Between (Title 22 CCR Sections 72519 and 73503)
- Submit a copy of the Transfer Agreement.
Bed or Service Request (Title 22 CCR Sections 72201, 72401, and 73445)
- Top of page under "Requested Beds" category -the "Approved Capacity" should be left blank.
- Bottom of page – check the types of services on this portion of the form.
Civil Rights Compliance Review
- Send directly to Office of Civil Rights – address is on last page of the form.
Change of Ownership
Submit all of the forms required for an "initial" application, listed above, plus the following:
- Copy of "Purchase Agreement" or "Operating Transfer Agreement".
- Written verification (with amount) by a certified public accountant, accounting for all patient monies being transferred to the custody of the new licensee. If none, need statement from current licensee that they didn't handle resident monies. [Title 22 CCR Sections 72529(a)(10) & 73557(a)(8)]
- Copy of receipt (with amount) signed by the new licensee in exchange for such monies. [Title 22 CCR Sections 72529(a)(10) & 73557(a)(8)]
- A letter from the prospective licensee to CDPH stating where the stored patient medical records will be maintained, and that the records will be made available to the previous licensee. [Title 22 CCR Sections 72543(e) & 73543(e)]