Forms and Supporting Documents
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Additional Instructions
(Each form listed also has instructions on the form)
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Cover Letter
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Cover Letter
Letter on company letterhead with the following information:
- License number
- Facility name and address
- Facility ID number (if known)
- Brief description of request
- 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/post/california-health-alert-network-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
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HS 200 (PDF, 1.5MB)
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Licensure & Certification Application
[Title 22 of the California Code of Regulations (CCR) section 74119(a)]
Tip
- Page 6, section B, item 6 — An organization will have its own Federal tax ID number
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Supporting Documents
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B.3- Organizational Chart - Owner Type
Submit a before and after 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
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
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Supporting Documents
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Indirect Ownership Agreement Submit an indirect ownership agreement
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HS 215A (PDF)
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Applicant Individual Information
[22 CCR section 74119(a)]
This form must be completed for the following individuals:
- New 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 ten percent or more in the applicant organization and/or parent organization
Tips
- Page 2, section B — 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 D; however, the resume must contain all required information requested in section D
- Page 7, section F — If answering yes to any question in this section, complete and attach the facility information sheet
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Supporting Documents
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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 Service. 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
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HS 309 Page 1 (PDF)
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Administrative Organization
Along with the HS 309, the following supporting documents according to organizational type must be submitted.
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Supporting Documents
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Corporation
- Filing Statement from the Secretary of State
- Articles of Incorporation
- By-Laws
- Foreign (out-of-state) applicants submit a copy Certificate of Qualification from the California Secretary of State
- 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 located in the top right corner of the applicant Articles of Incorporation
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Supporting Documents
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Limited Liability Company (LLC)
- Filing Statement from the Secretary of State
- Articles of Organization
- Operating Agreement
- Foreign (out-of-state) applicants submit a copy Certificate of Qualification from the California Secretary of State
- List of Managing Members (only if additional space is needed to input all managing members)
Tip
- Page 1, item 3 — The organization date is located in the top right corner of the applicant Articles of Organization
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HS 309 2nd Page (PDF)
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Organizational Structure
Only complete fields that are applicable to applicant’s entity type
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Supporting Documents
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Public Agency
Copy of signed Resolution
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Supporting Documents
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Partnership
Copy of signed Partnership Agreement
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