HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Contact Us

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

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.

Initial License
Medicare
Medi-Cal

Checklist and Instructions - Please submit your documents in this order

Required Documents for an Initial License

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: Facility name and address 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/post/california-health-alert-network-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 1265 and Title 22 California Code of Regulations (CCR) section 72201 Tip Page 6, Section B, item 6 — This parent company will have its own Employer Identification Number (EIN). If applying for Med-Cal, applicant must complete the “Subcontractor Information and Significant Business Transactions” attachment Note: Page 7, section C, item 3 – The name of the proposed facility cannot have the word “Rehabilitation” in the facility name unless the facility has previously had a rehabilitation services 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 – Submit evidence that the licensee has sufficient financial resourced to operate the facility for at least 90 Days Note: The Provider will need to contact CAB to obtain the rate for Initials.
Supporting Documents	A.11 – Department of Health Care Access and Information (HCAI) and/or Certificate of Occupancy SNF: HSC section 1276 and 1275 and 22 CCR section 72205 and 72601 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 HCAI (https://hcai.ca.gov/) for Title 24 clearance: [22 CCR sections 72601 & 73601]
Supporting Documents	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: Applicant’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 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)]
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)
Supporting Documents	C.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
Supporting Documents	D.1 - Control of Property SNF: HSC 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 Must include name and address of any persons, organizations, or entities that own the real property on which the facility seeking licensure
Supporting Documents	Floor Plan Submit a floor plan that coincides with your office space
HS 215A (PDF)	Applicant Individual Information This form must be completed for the following individuals: Administrator, Director of Nursing, and Medical Director of the facility Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization and/or Management Company Each individual having a beneficial interest of five percent or more in the applicant organization and/or parent 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 included 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 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) Individual’s nature of involvement Individual’s dates of involvement
Supporting Documents	Resume SNF: HSC section 1261.4 and 22 CCR sections 72007 and 72327 A resume is required for the Administrator(s), Director of Nursing (DON), and Medical Director Note: Administrator must be a licensed Nursing Home Administrator (NHA) DON must be a licensed Registered Nurse
	Certificate (Medical Director) SNF: HSC section 1261.4 Copy of Certified Medical Director certificate issued by the American Board of Post-Acute and Long-Term Care Medicine (ABPLM) Note: If Medical Director is not certified, provide proof of progress towards certification via: Copy of certification initiation letter issued by ABPLM that includes the Medical Directors expected date of certification. Attestation Letter – Or Signed by the applicant (Medical Director) affirming that they are aware and will comply with the requirements of Health and Safety Code section 1261.4.
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 LLC 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
HS 400 (PDF)	Affidavit Regarding Patient Money SNF: HSC section 1318 and 22 CCR section 72217 Mark either A or B box. If B is checked, enter the amount of patient monies managed and submit the bond required on form HS 402 Tip If you are a sole proprietor, you would enter your legal name If the money you are going to handle is outside the table, your bond should be $1,000 more. For example, you will handle $25,000, your required bond amount will be $26,000
HS 402 (PDF)	Surety Bond Verification SNF: HSC section 1318 and 22 CCR section 72217 Must be signed by the bonding agency Provide a copy of the seal and copy of the bonding agency Submit a copy of the bond or Power of Attorney form Tip Please check the upper right-hand corner of this form to ensure you are submitting the CA Department Public Health form (not the Department of Social Services’ form) Licensee name dba facility name is acceptable Submit the original form with the raised embossed seal on all documents
HS 602 (PDF)	Transfer Agreement SNF: HSC section 1760.4 and 22 CCR section 72519 Copy of current written transfer agreement with a General Acute Care Hospital Tip The Facility Administrator has the authority to sign this form The facility may not have a Facility Provider Number yet, and may be left blank
CDPH 609 (PDF)	Bed or Service Request SNF: HSC section 1265 and 22 CCR section 72211, 72603, and 72201 Complete the columns marked “Requested Beds” and “Requested Services”
STD 850 (PDF)	Fire Safety Inspection Request SNF: 22 CCR section 72205 The STD 850 form is required for initial applications or construction. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form. The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form
Supporting Documents	Applications for Supplemental Services SNF: HSC sections 1252,1253,1265, and 1268 and 22 CCR sections 72401 Include the forms corresponding with the type of service the SNF is requesting to add to the license CDPH 242: Chronic Dialysis Service CDPH 259: Rehabilitation Center (Outpatient Only) CDPH 260: Occupational Therapy Service (Outpatient Only) CDPH 261: Physical Therapy Service (Outpatient Only) CDPH 262: Speech Pathology and/or Audiology Service (Outpatient Only) CDPH 255: Social Work Service All the forms required for SNF additional services can also be requested for ICF except for the service requested below: CDPH 609: Special Treatment Program Service (For SNF Only)
CLIA	Clinical Laboratory Improvement Amendments (CLIA) Waiver Submit a copy of approved CLIA waiver

Medi-Cal Certification Documents

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

HS 328 (PDF)

Notice - Effective Date of Provider Agreement

If applying for both Medi-Cal and Medicare certification, only submit one copy of this form

DHCS 9098 (PDF)

Medi-Cal Provider Agreement

Do not leave any questions blank. Enter “same” or “N/A” if not applicable
The mailing address must be the same as reported on the HS 200 form, section C, Page 3, item 4
Notarized signature page is required
Submit the “Acknowledgement” page from the notary public

Medicare Certification Documents

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
CMS 671 (PDF)	Long Term Care Facility Application for Medicare & Medicaid Note: F14 – if a parent company was identified on the HS 200, B.6., enter the same name here
CMS 1561 (PDF)	Health Insurance Benefits Agreement Submit two (2) signed forms with signatures: Sign the bottom signature block entitled “Accepted for the Successor Provider of Services By”
HHS 690 (PDF)	Assurance of Compliance The Office of Civil Rights (OCR) online portal is: Office for Civil Rights (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf) Once the online submission is completed, an electronic notification from OCR stating the Assurance of Compliance form was submitted successfully will be received by the applicant Submit a copy of this notification
CMS 855A (PDF)	Medicare General Enrollment Health Care Providers/Supplier Application This application is from the Federal Department of Health and Human Services The completed application should be mailed directly to the appropriate fiscal intermediary

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