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
  

• Previous and proposed/new location

• 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

​

• ​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 - Construction

A certificate of occupancy is not required

​B.3 - Organizational Chart - Owner Type

Submit an organizational chart if the owner is a 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 they are operating- see B.6​
  

​Applicant Individual Information 

[22 CCR section 74105 and 74201] and [HSC section 1405]
This form must be completed for the following individuals and include signatures and dates:

• Owners, agency manager, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization

• Each individual having a beneficial interest of exceeding 10 percent or more in the applicant organization and/or parent organization

Tips:

• Page 2, section B, Item 3 — 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 term 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, must complete section H for the Facility Information Sheet
  

Administrative Organization

[22 CCR section 74105(a)(8)] and [HSC section 1405(h)]

Along with the HS 309, depending on organizational type, the following supporting documents must be submitted:

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)
  

Public Agency

Copy of signed Resolution

Schedule of Fees

[22 CCR section 74105(a)(10)] and [HSC section 1405(j)]

• Received a schedule of fees to be charged and collected

• Received a statement of the method by which each fee is to be computed or determined