​​Additional Instructions

(​​​Each form listed also has instructions on the form)​

DDS Approved Program Plan

ICF/DD and ICF/DD-H: Health and Safety Code (HSC) section 1267.7

ICF/DD: Title 22 California Code of Regulations (CCR) section 76307 and 76309

ICF/DD-H: 22 CCR section 76856(a)

Submit a copy of the approved program plan from Department of Developmental Services (DDS)

ICF/DD and ICF/DD-H: HSC section 1267.8

ICF/DD: 22 CCR section 76213

ICF/DD-H: 22 CCR section 76847(b)

For Initial, submit one of the following regardless if construction occurred or not:

• Evidence of compliance with local building code requirements or;
• Certificate of Occupancy issued by the local building authority
  

​B.3 - Organizational Chart - Owner Type

ICF/DD: 22 CCR section 76205(a)

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
  

ICF/DD: 22 CCR section 76205
This form must be completed for the following individuals and include signatures and dates:

• Administrator of the facility and Administrator Designee
• 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 5 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 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, must complete section H for the Facility Information Sheet

Administrative Organization

ICF/DD: 22 CCR section 76205(a)(2)

Along with the HS 309, the following supporting documents according to organizational type 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

Transmittal Application for Criminal Background Investigation

ICF/DD and ICF/DD-H: HSC section 1265.5

ICF/DD: 22 CCR section 76209(a) and 76513(b)

ICF/DD-H: 22 CCR section 76845

For ICF/DD: complete form for the following individuals and mail to the address indicated on the form:

• Owners with a five percent or more direct or indirect ownership
• Administrator
• Managers/members/directors/officers​
  

• ​Administrator
  

Consultant Letter

ICF/DD and ICF/DD-H: HSC section 1265.5(h)​

If a consultant requests to be exempt from having to obtain multiple background checks, a letter signed by the licensee owners or officers must be SUBMITTED stating that the following criteria have been met:

• Is employed as a consultant and acts as direct care staff
• Is a registered nurse, licensed vocational nurse, physical therapist, occupational therapist, or speech-language pathologist
• Has obtained a criminal record clearance as a prerequisite to holding a license or certificate to provide direct care services
• Has a license or certificate to provide direct care services that is in good standing with the appropriate licensing or certification board
• Is providing time-limited specialized clinical care or services
• Is not left alone with a client
  

Surety Bond Verification

ICF/DD: 22 CCR section 76241(a)

ICF/DD-H: 22 CCR section 76852.2(a)

• Is signed by the bonding agency
• Possesses the embossed or raised seal of the bonding agency
• A copy of the bond is acceptable and does not have to be an original, however the embossed or raised seal of the bonding agency and Power of Attorney must be visible
• Form is only required when applicable

Tips

• Please check the upper right-hand corner of this form to ensure you are submitting the CA Department Public Health form (not the Department of Social Services’ form)

Licensee name dba Facility name is acceptable

Civil Rights Compliance Review

Send directly to Office of Civil Rights – address is on last page of the form

Additional Instructions

(Each form listed also has instructions on the form) ​

• 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