Cover Letter

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
  

A.10 – California Department of Health Care access and Information (HCAI) and/or Certificate of Occupancy

[Title 24 California Code of Regulations (CCR) part 2 sections 111 and 1226.2] [HSC section 1226]

One of the two documents are required:

• ​Written certification: The local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements:
  

• California Building Code (CBC)
• California Fire Code (CFC)
• California Electrical Code (CEC)
• California Mechanical Code (CMC)
• California Plumbing Code (CPC)
• California Administrative Code (CAC) 

CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by the local building authority

Note: Title 24 compliance does not apply to CHOWs unless there has been construction and/or remodeling

If construction occurred and if the construction resulted in a new building or addition:

• Submit a Certificate of Occupancy
• This is not applicable if there were alterations or repairs to existing buildings performed or conversion of space

[HSC section 1212]

Submit additional information, including all ownership and facility information, date, and any final action

[HSC section 1212]

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 Change
• Letter 147-C (EIN Confirmation Notification)
• Form SS-4 (Confirmation Notification)
  

D.1 – Control of Property

[HSC section 1212]​

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

Federal Regulations (CFR) section 455 subpart B and 420 subpart C] [HSC section 1212]

This form must be completed for the following new individuals:

• Administrator of the facility
• Parent Company (if applicable)
• Directors, board members, corporate officers of the PARENT organization
• Owners, officers, directors of management company, if applicable

• Individual direct and indirect owners with 10 percent or more ownership interest in the applicant entity
• Officers and directors of applicant and any entities with 10 percent or more ownership interest in the applicant

• Individual direct and indirect owners with five percent or more ownership interest in the applicant entity
• Officers and directors of applicant and any entity with five percent or more ownership interest in the applicant 
  

Tips

• Page 2, section B — 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 — 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 — If answering yes to any question in this section, complete Section H: Facility Information Sheet
  

​Resume

[HSC section 1212]

A resume is required for the Administrator(s)

Corporation (if applicable)

[HSC section 1212]

• 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)
• A copy of the Resolution authorizing the filing of the application
• A copy of authorization of a foreign (out of state) corporation to do business in California

• 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
  

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

Fire Safety Inspection Request (not applicable for a CHOW) 

[HSC section 1226(f)]​

The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form.

• 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 8, item 3.c.1
• Notarized signature page is required
• Submit the “Acknowledgement” page from the notary public