Health care Facility Licensing and Certification

Hospice Agency

Initial and Change of Ownership Multiple Location Application Checklist

Effective January 1, 2022, Senate Bill (SB) 664 institutes a moratorium on new hospice license. During the moratorium, CDPH will be prohibited from issuing a new license pursuant to Health and Safety Code (HSC) section 1751.70. However, according to HSC section 1751.75, CDPH may grant an exception to the moratorium.

Step 1: Individuals or entities interested in applying for hospice licensure must begin by submitting an exception request. This consist of submitting a written justification and supporting documentation to demonstrate need based on geographic concentration to the Centralized Applications Branch (CAB). If CAB determines there is a need based on geographic concentration, CAB will notify the applicant they may apply for licensure. Do not submit the required documents listed in the table below for licensure prior to submitting an exception request and receiving CAB determination.

Stop Here: If you have submitted an exception request, and CAB denied your request you are denied submitting an application. Do not submit an application seeking hospice licensure. Pursuant to SB 664 and HSC 1751.70, CDPH cannot issue you a license to operate a hospice.

For additional information, please refer to AFL 21-53 on the CDPH website (www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-21-53.aspx).

Step 2: If you received notice from CAB that your exception request was accepted, you may submit an application to CAB with a copy of your acceptance letter. 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.

Initial License
Change of Ownership (CHOW)

Checklist and Instructions - Please submit your documents in this order

Required Documents for an Initial License or CHOW

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: License number (only applicable for CHOW) Facility name and ID number (if known) Brief description of request Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address) The Department will use the invoice contact email address to invoice the application fee 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
SB 664 Supporting Document	Attach a copy of your SB 664 – hospice moratorium acceptance letter received from CAB. Ensure the business address reflects the application package entirely. Your application will automatically be denied if the business address on the licensure application packet is different or inconsistent to the business address on SB 664 – hospice moratorium acceptance letter.
HS 200 (PDF, 1.5MB)	Licensure & Certification Application (Revised 07/2023) [Health and Safety Code (HSC) section 1748(b)]. Tips: Page 3, section A, item 9 – If the facility, agency, or clinic indicates they operate 24/7/365, complete "b" to indicate the hours of operations for the public. This information is used for surveying purposes. Page 3, section B, item 2 – Provide the Federal Tax Identification Number/Employer Identification Number of the licensee. Do not enter a Social Security number in this field. Page 6, section B, item 6 – An organization must own 100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN)
Supporting Documents	IRS - Internal Revenue Service Documentation Submit one of the following IRS tax documents showing the licensee’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
Supporting Documents	B.3 - Organization Chart Submit an organizational chart if the type of entity, identified on the HS 200 is a for-profit corporation, limited liability company (LLC), limited liability partnership, limited partnership, or non-profit . 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 If the licensee is a subsidiary of another organization Licensee identified in Section B.1, submit an organizational chart to display the relationship Parent company of applicant, if applicable, and all the licensed agencies/facilities it is operating - see B.6
Supporting Documents	Section D - Evidence of Control of Property Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee If the licensee owns the property, submit a signed copy of the Grant Deed, or Bill of Sale If the licensee rent, lease, or sublease, submit the signed copy of the agreement (i.e., rental agreement and/or master lease between the property owner/manager and the perspective licensee)
Supporting Documents	Floor Plan Submit a floor plan that coincides with your office space
CMS 855A (PDF) (Page 24 only)	Geographical Service Area (GSA) [HSC section 1746(i) and 1748(a)] Additional hospice sites cannot establish a new additional site outside of the hospice parent agency approved GSA Submit the list of the parent agency approved GSA (including cities, counties, and zip codes) Submit a web-based map reflecting the distance between the parent agency and the additional hospice site

Required Documents for a CHOW Only

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Supporting Documents

Copy of Purchase Agreement or Operating Transfer Agreement
A letter from the prospective licensee (to CDPH) stating the location where the stored patient medical records will be maintained and affirming the records will be made available to the previous licensee [SQHC, 2003, Section 6.3 (B)(3)(g)]