āForms and Supporting Documentsā
| āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
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āCover Letter
| Cover Letterā 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
- Location Information
- Contact information (name, title, phone number, and e- mail address)
- Emergency Contact Information (name, email, alternate email, phone, fax, 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)
- Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address)
- Signaātureā
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āHS 200 (PDF)
| Licensure & Certification Application
[Health and Safety Code (HSC) section 1250.3 and 1254.2] [Title 22 California Code of Regulations (CCR) section 79101]
Tips:ā - Page 6, Section 6 ā 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)
- āPage 9, Section 5 ā When listing the names of individuals with direct or indirect ownership of the facility in Section 5, provide the EIN (do not enter a Social Security number in this field)
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āSupporting Documents
| āA.10 - Construction
[22 CCR section 79105]
Submit evidence of compliance with local building code requirements whether or not construction occurred
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āSupporting Documents
| āB.3 - Organizational Chart - Owner Type Submit an organizational chart if the owner is a profit, 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.6ā
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āSupporting Documents
| āD.1 - 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 licenseeāāā
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āSupporting Documents
| āE. Management Company Agreement (If applicable)ā Facilities operated under a Management Agreement between the licensee and management company must complete and submit Attachment E-1 (Management Company Information) on HS200 along with a copy of the Management Agreement. The Management Agreement must state that the licensee is responsible for the facility
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āCDPH 609 (PDF)
| āBed or Service Request- For new facilities or initial licensure, complete the columns marked āRequested Beds" and āRequested Services"
- For currently licensed facilities or Change of Ownership complete the columns marked āExisting Beds" and āExisting Services" and the columns marked āRequested Beds" and āRequested Services"
- For CHOW applications, the information marked in the āExisting" and āRequested" fields must be the same.
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āSupporting Documents
| āWritten Listing of Services [22 CCR section 79101(d) and 79251]
Submit a detailed written listing of those services to be offered or provided by the hospital. The detailed written listing shall include but not be limited to: - Age range of patients for whom care will be provided.
- Classifications of chemical dependencies to be treated.
- Descriptions of each of the specific elements of the overall treatment program.
- All proposed modifications to existing approved treatment programs.
Note: In addition to the basic services as specified in Title 22 CCR sections 79201 through 79221, a chemical dependency recovery hospital may be approved by the Department to provide one or more of the following optional supplemental services: - Medical detoxification
- Treatment programs for adolescents who have a chemical dependency
- āAny other services which are provided for the treatment of chemical dependency, but are not addressed in regulations shall have the prior approval of the Departmentā
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āCDPH 709 (PDF)
| āClient Accomodation Analysisā- Complete this form in its entirety
- Must be signed
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āSupporting Documents
| āFloor Plan Submit a floor plan that coincides with the room schematics on the CDPH 709
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āHS 215A (PDF)ā
| āApplicant Individual Information
[HSC section 1265.1]
This form must be completed and signed for the following individuals:
- Administrator and Medical Director of the facility
- Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization and/or Management Company
- 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.3 ā 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 ā 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 D; however, the resume must contain all required information included in Section D
- Page 7, Section F ā If answering yes to any question in this section, complete and attach the facility information sheet
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Supporting Documentsā
| 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
- āIndividual's dates of involvement
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āSupporting Documents
| āResume [22 CCR section 79309(a) and 79301]
A resume is required for the Medical Director and Administrator
- If the Medical Director also serves as the Administrator only one resume is needed
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HS 309 1st Pageā (PDF)
| Administrative Organization Along with the HS 309, depending on the organizational type, the following supporting documents must be submitted:
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Supporting Documentsā
| 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)
āTip
- āPage 1, item 3 ā The incorporation date is located in the top right corner of the applicant Articles of Incorporation
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Supporting Documentsā
| 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)ā
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āHS 309 2nd Pageā (PDF)
| Organizational Structure Only complete fields that are applicable to applicantās entity type.
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āSupporting Documents
| Public Agency Copy of signed Resolution
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āSupporting Documents
| Partnership Copy of signed Partnership Agreement
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āHS 400 (PDF)
| āAffadavit Regarding Patient Money [22 CCR section 79119(b)]
- Mark either A or B box. If B is checked, enter the amount of patient monies managed and submit the bond required on form HS 402
Note: HS 400 is only required when applicable
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āHS 402ā (PDF)
| āSurety Bond Verification [22 CCR section 79119]
Chemical Dependency Recovery Hospitals which handle $25.00 or more per patient or $500.00 or more for all patients within any one month, shall post a bond in accordance with the amounts listed on the HS 400 Affidavit Regarding Patient Money
Note: HS 402 only required when applicable
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| Transfer Agreement [22 CCR section 79319]
CDRH shall have current written transfer agreement(s) with one or more general acute care hospitals for the provision of acute medical services.
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STD 850āā (PDF)ā
| Fire Safety Inspection Request [22 CCR section 79105]
The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form.
Note: This form is NOT required for a CHOW
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