The California Department of Health Services (CDHS), Licensing and Certification (L&C) Program has revised and updated the Applicant Individual Information HS 215A (7/06) form. Please begin using the revised form effective immediately.

The revised form is to be used by all facility types for all “initial” and “change of ownership” (CHOW) application packages. In addition, this form must be completed for disclosure purposes when changes are reported. For example, changes in an administrator, general partner, trustee or trust applicant, sole proprietor, executor, corporate officer or director, share holders, parents or subsidiaries, facility agents, managers, and limited liability company members, as required by law, even though no change in legal ownership is occurring. Please refer to the HS 215A form for instructions on its completion.

The HS 215A form may be obtained from the L&C/CDHS Centralized Applications Unit (CAU) website.

1.  The L&C/CDHS CAU currently processes “initial” and “CHOW” application packages for the following facility types and management companies (refer to either website, listed above, for a complete list of forms that need to be completed for an “initial” or “CHOW” application package and for mailing instructions):
   (a) Skilled Nursing Facility (SNF)
   (b) Intermediate Care Facility (ICF)
   (c) Intermediate Care Facility for Developmentally Disabled
   (d) Intermediate Care Facility for Developmentally Disabled -- Habilitative
   (e) Intermediate Care Facility for Developmentally Disabled – Nursing
   (f) Primary Care Clinics (including Rural Health Clinics)
   (g) Management Company for a SNF or ICF
2. The L&C/CDHS district offices currently process the HS 215A form for the following:
   (a) “Initial” and “CHOW” application packages for all “OTHER” FACILITY TYPES (including home health agencies) that are not listed on the previous page.
   (b) ALL DISCLOSURE CHANGES for all facility types. These changes must be reported to the appropriate district office within the time specified by law for that facility category.
   
   For these changes handled by the L&C/CDHS district offices, you may download and fill in the HS 215A form from either website listed on the previous page. However, you must submit the form directly to your respective L&C/CDHS district office. A list of district offices and appropriate contacts are located on the L&C/CDHS Contact Us website.

If you have any questions regarding this letter, please contact Lisa Hall, Chief of the Centralized Applications Unit at LHall1@dhs.ca.gov or (916) 552-8666.

Sincerely,

Original Signed by Anna Ramirez

Anna Ramirez, Chief
Field Operations Branch - Coastal