​Cover Letter

Letter on company letterhead with the following information:

• Facility name and address

• Facility ID number (if known)
  

• Brief description of request​
  

• Applicant Contact Information (name, title, phone number, applicant contact email address)
  

• The Department will use the applicant contact email address to send all application correspondence

• General Contact Information (name, title, phone number, fax, email address, and alternative contact information)

• The Department will use this information to contact the facility for day-to-day business

• Emergency Contact Information (name, phone number, fax, email address, alternate email, 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)

• All Facility Letter Contact Information (name, phone number, fax, and email address)

• The Department will use this information to send All Facility Letters

• Facility Contact (Public Use) Information (phone number, fax, email address, and website address)

• The Department will use this information to store facility contact information for the public

• Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)

• The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents​​​

• Signature
  

A.10 – California Department of Health Care Access and Information (HCAI) [22 CCR sections 79583, 79819, 79821] And/ Or Certificate of Occupancy

Contact HCAI or the local building authority for Title 24 clearance​

If the facility is newly constructed or a remodeled building, submit the following:

• Submit a HCAI Certificate of Occupancy or Construction Final

Applicant Individual Information

[22 CCR sections 79629, 79775, 79777]​

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

• Administrator of the facility

• Medical Director

• Director of Nursing

• Applicant

• ​Directors, board members, officers (Chief Executive Officer, President, Chief Operating Officer, Chief Financial Officer)

​​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

[22 CCR sections 79777, 79629 and 79775]

A resume is required for the Administrator, Director of Nursing and Medical Director

​Administrative Qualifications

[22 CCR section 79777(d)]

The Administrator shall submit a copy of one of the following qualifications:

• Master’s degree in Health Services Administration

• Master’s degree in a health-related field

• Bachelor’s degree in a health-related field

• State civil service appointment as a Correctional Health Services Administrator
  

Administrative Organization

[22 CCR section 79773]

Along with the HS 309, the following supporting documents according to organizational type must be submitted:

Public Agency

[22 CCR section 79773]

Copy of signed Resolution

Fire Safety Inspection Request

[Title 22 CCR sections 79583, 79825]

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.