HEALTH CARE FACILITY LICENSING AND CERTIFICATION

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Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

For application status requests, please include the following in your email:

Application ID (if applicable)
Name of Facility or Agency
License or Facility/Agency # (if applicable)
Address
Facility or Provider Type
Date Documentation Sent
Contact Number

Home Health Agency

Initial and Change of Ownership Application Checklist

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)
Medicare
Medi-Cal

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 Facility name and ID number (if known) Brief description of request Previous and proposed/new location 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) Signature
HS 200 (PDF)	Licensure & Certification Application [Title 22 California Code of Regulations (CCR) section 74661 Health and Safety Code (HSC) section 1728] Note: Page 2, section A, item 5 & 6 – Specific capitalization evidence is required for a licensed-only HHA (i.e., with no Medi-Cal or Medicare): Any HHA that is going to be licensed-only will need to submit evidence that the licensee has sufficient financial resources to operate the HHA for the first 3 months [Title 22 CCR section 74661 (a)(6)] including: Projected expenses for the first 3 months (90 days) of operation broken down by rent, utilities, salaries, overhead, etc. A copy of an “official" bank statement, certificate of deposit, etc. (in the name of the licensee) providing current balances Tip: 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 EIN of the licensee. Do not enter the 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 entity'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 - Organizational Chart - Owner Type 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 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 Note: Submit the HS 215A form for each of these individuals
HS 200 (PDF)	Section C.1 – Management Agreements Item B: HHA has no authority to allow management companies. The SNF management companies' authority cannot be used for an HHA. Additionally, interim management agreements between the proposed owner and the current owner cannot be accepted for HHA applicants.
Supporting Documents	Section D – Property Information 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 Grand 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
Supporting Documents	Section F.1 - Subcontractor Information and Significant Business Transactions If the current or proposed agency is applying for Medi-Cal certification, complete and submit the Attachment F-1: Subcontractor Information and Significant Business Transactions. Note: The attachment F-1 document replaces the DHCS 6207 Medi-Cal Disclosure Statement entirely.
HS 215A (PDF)	Applicant Individual Information [CCR section 74661 (a)(5) & 74665 HSC section 1728] This form must be completed and signed for the following individuals: Administrator and the Director of Patient Care Services of the facility Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization Each individual having a beneficial interest of five percent or more in the applicant organization and/or parent organization Tip: Page 2, section B, item 3 — The date of birth is an identifier, as several people may have the same name. This will ensure each individual is associated with the correct facility or entity Page 2, section B, item 4 – Provide your Driver's License Number or a State-Issued identification Card Number. Attached a copy of the Driver's License or State-Issued Identification Card for verification. Page 2, section B, item 5 – The Social Security Number is an identifier, as several people may have the same name. this will ensure each individual is associated with the correct facility or entity Page 3, section B, item 7 – Administrator must list the number of hours spent at each agency per week. 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 D; 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.
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
Supporting Documents	Resume A resume is required for the Administrator and Director of Patient Care Services
HS 309 1st Page (PDF)	Administrative Organization Along with the HS 309, the following supporting documents according to organizational type must be submitted:
Supporting Documents	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) Tip: Page 1, item 3 — The incorporation date is in the top right corner of the applicant Articles of Incorporation
Supporting Documents	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)
HS 309 2nd Page (PDF)	Organizational Structure Only complete fields that are applicable to applicant’s entity type
Supporting Documents	Public Agency Copy of signed Resolution
Supporting Documents	Partnership Copy of signed Partnership Agreement
CDPH 322 (PDF)	Transmittal Application for Criminal Record Clearance [HSC section 1728.1(a)(2)(A)] Submit the CDPH 322 form for the following individuals: Owners with a five percent or more direct or indirect ownership Administrator Note: Mail this form to the address indicated on the form
CDPH 325 (PDF)	Criminal Record Clearance Submissions [HSC section 1728.1(a)(2)(A)) Submit the CDPH 325 form with for the following individuals' names listed on the form: Owners with a five percent or more direct or indirect ownership Administrator
BCIA 8016 (PDF)	Request for Live Scan Service For out-of-state fingerprint clearance, contact the Centralized Applications Branch at (916) 552-8632 or by e-mail: CAB@cdph.ca.gov Instructions for completion of the BCIA 8016 form are available on the Attorney General's website: https://oag.ca.gov/fingerprints Refer to the "Sample" BCIA 8016 form on the L&C "Applications for a Home Health Agency" website: https://www.cdph.ca.gov/ Programs/CHCQ/LCP/Pages/HealthAgency-HHA.aspx The ORI# must be "A1226." Submit the BCIA 8016 form for the following individuals: Owners and Administrator
CMS 855A Page 23 (PDF)	Geographic Areas of HHA [CCR sections 74607, 74663, and 74664] The service area of a parent HHA may not extend beyond four (4) hours surface travel time from the agency unless the agency serves a rural, scarcely populated area, under certain conditions Submit a list of the geographical areas (including cities, counties, and zip codes) to be served Submit a web-based map

Required Documents for a CHOW Only

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Supporting Documents

All the forms required for an Initial application listed above in addition to the documents requested below:

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 [Title 22 section 74731(g)]

Note:

A CHOW shall be deemed to have occurred where, when compared with the information contained in the last approved license application, the licensee has changed one of the following [Title 22 section 74667 (a)]:
Transfer of 50 percent or more of the issued stock of a corporate licensee
Transfer of 50 percent or more of the assets of the licensee
Change in partners or partnership interest of 50 percent or greater in terms of capital share of profits
Relinquishment by the licensee of the management of the agency
A transfer of stock less than 50 percent is a stock transfer change and a Report of Change Application must be submitted to the Department

Medi-Cal Certification Documents

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
HS 328 (PDF)	Notice – Effective Date of Provider Agreement If applying for both Medi-Cal and Medicare certification, only submit one copy of this form
DHCS 9098 (PDF)	Medi-Cal Provider Agreement Do not leave any questions blank. Enter “same" or “N/A" if not applicable The mailing address must be the same as reported on the HS 200 form Notarized signature page is required Submit the "Acknowledgement" page from the notary public, if applicable
Supporting Documents	National Provider Identifier (NPI) Submit NPI approval letter
Capitalization Financial Resources	Capitalization Financial Resources These capitalization requirements are only for a licensed HHA to be certified with Medi-Cal The Provider Certification Unit must approve the capitalization plan prior to conducting a Medi-Cal certification survey If an HHA applicant wants Medi-Cal "only" submit the following capitalization evidence: Business Plan Structure Projected Expenses for the first three months (90 days) of operation broken down by rent, utilities, salaries, overhead, etc. Copy of an "official" bank statement, certificate of deposit, etc. (in the name of the licensee) providing current balances. Must show that the applicant has available funds to operate the HHA for the first three months and that at least 50% are non-borrowed funds An attestation (signed and dated) from an Officer of the bank that the funds are in the account(s) and that the funds are immediately available An attestation (signed and dated) from the licensee that the required funds are immediately available Projected number of visits for the first three months of operation Projected number of visits for the first year of operation following certification (this is N/A if licensed "only")

Medicare Certification Documents

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
HS 328 (PDF)	Notice – Effective Date of Provider Agreement If applying for both Medi-Cal and Medicare certification, only submit one copy of this form
CMS 1561 (PDF)	Health Insurance Benefits Agreement Submit two (2) signed copies with “original" signatures: Initial Application: Sign the top signature block entitled “Accepted for the Provider of Services By" CHOW: Sign the bottom signature block entitled “Accepted for the Successor Provider of Services By"
CMS 1572 (a) & (b) (PDF)	Home Health Agency Survey and Deficiency Report The CMS 1572 form is required Complete pages (a) and (b), items 1-20, as indicated on the form Note: If licensed “only", the CMS 1572 form is required to document the services requested and to assist the local district office with the survey process. If requesting certification, the CMS 1572 form is required to apply for Medicare certification.
HHS 690 (PDF)	Assurance of Compliance The Office of Civil Rights (OCR) online portal is: Office for Civil Rights (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf) Once the online submission is completed, an electronic notification from OCR stating the Assurance of Compliance form was submitted successfully will be received by the applicant Submit a copy of this notification
CMS 855A (PDF)	Medicare General Enrollment Health Care Provider/Supplier Application This application is from the Federal Department of Health and Human Services The completed application should be mailed directly to the appropriate fiscal intermediary

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