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HEALTH CARE FACILITY LICENSING AND CERTIFICATION

End-Stage Renal Disease

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 - Please submit your documents in this order

Required Documents for a Change of Governing Board 

Forms an​d Supporting Docu​​ment​​s

Additional Instructions

(Each form listed​ also has instructions on the form)

Cover Letter

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

  • 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 

HS 2​00 (PDF, 1.5MB)​

Licensure & Certification Application

Tip

  • Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions

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 the licensed agencies/facilities they are operating - see B.6

HS​ 215A (PDF)​

Applicant Individual Information
The form must be completed and signed for the following individual(s):

  • Applicant Organization

    • Owners, directors, board members, corporate officers, LLC members/managers, partners, and/or trustees of the applicant organization and/or Management Company

Tips

  • Section B – List applicant’s legal name, nature of involvement to the facility, date of birth, driver’s license or state-issued identification number and expiration date, social security number

  • 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

  • Section F — If answering yes to any question in this section, complete and attach the facility information sheet (section H)

Supporting Documents

Facility Information Sheet

Every 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 Service. 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

HS 309 P​age 1 (PDF)​

Administrative Organization

Along with the HS 309, depending on organizational type, the following supporting documents 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

Supporting Documents


Limited Liability Company (LLC)

  • Filing Statement from the Secretary of State

  • Articles of Organization

  • Operating Agreement

  • List of Managing Members (only if additional space is needed to input all managing members)

HS 309 Pa​ge 2 (PDF)​


Organizational Structure

Only complete fields that are applicable to applicant’s entity type

Supporting Documents


Public Agency

Copy of signed Resolution

Supporting Documents

Partnership

Copy of signed Partnership Agreement​​

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