Forms and Supporting Documents
| Additional Instructions
(Each form listed also has instructions on the form)
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Cover Letter
| Cover Letter
Letter on company letterhead with the following information:
Proposed Parent Facility (Primary Site) Facility name and address Facility ID number (if known) Brief description of request to operate an extension site Statement that the OPT/SP extension location is located sufficiently close to share administration, supervision, and services with the primary site.
Applicant Contact Information (name, title, phone number, applicant contact email address) General Contact Information (name, title, phone number, fax, email address, and alternative contact information) Emergency Contact Information (name, phone number, fax, email address, alternate email, and phone number that will receive text messages) All Facility Letter Contact Information (name, phone number, fax, and email address) Facility Contact (Public Use) Information (phone number, fax, email address, and website address) Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)
Extension Site Facility name and address
Applicant Contact Information (name, title, phone number, applicant contact email address) General Contact Information (name, title, phone number, fax, email address, and alternative contact information) Emergency Contact Information (name, phone number, fax, email address, alternate email, and phone number that will receive text messages) All Facility Letter Contact Information (name, phone number, fax, and email address) Facility Contact (Public Use) Information (phone number, fax, email address, and website address) Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)
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HS 200 (PDF, 1.5MB)
| Licensure & Certification Application
[Title 42 Code of Federal Regulations (42 CFR) section 485.709, 420 Subpart C, and 455 Subpart B] |
Supporting Documents
| A.10 – Certificate of Occupancy [42 CFR section 485.723(a)(1)]
If construction occurred and if the construction resulted in a new building or addition: |
Supporting Documents
| B.3 – Organizational Chart – Owner Type [42 CFR section 485.709(a)]
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 it is operating- see B.6
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Supporting Documents
| B.3 – Non-Profit Status – Owner Type
Submit a copy of the IRS Tax Exempt Determination Letter showing the non-profit 501(c)(3) status (if applicable)
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Supporting Documents
| B.4.b – License Revocation (if applicable)
Submit additional information, including all ownership and facility information, date and any final action
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Supporting Documents
| B.6 – Organizational Chart [42 CFR section 485.709(a)] If licensee is a subsidiary of another organization, an organizational chart must be submitted
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HS 215A (PDF)
| Applicant Individual Information [42 CFR sections 420.206(a)(3), 455.104, 485.709(a)] This form must be completed and signed for the following individuals:
Administrator of the facility Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization Owners, directors, board members, corporate officers, LLC members/managers, and partners of the parent, grandparent, great grandparent, and etc. organization, if applicable Each individual having a beneficial interest of exceeding five percent or more in the applicant organization and/or parent, grandparent, great grandparent, and etc. organization
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
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Supporting Documents
| Facility Information Sheet Each 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 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
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Supporting Documents
| Resume
[42 CFR section 485.705 (c)(1)] A resume is required for the Administrator
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Supporting Documents
| Bachelor’s Degree
[42 CFR section 485.705(c)(1)]
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HS 309 1st Page (PDF)
| Administrative Organization [42 CFR section 485.709(a)]
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HS 309 2nd Page (PDF)
| Organizational Structure
Only complete fields that are applicable to applicant’s entity type
Tip |
| Fire Safety Inspection Request [42 CFR section 485.723(a)(1)]
The STD 850 form is required. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form
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