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:

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

Rehabilitation Clinics and Comprehensive Outpatient Rehabilitation Facility

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)
Medi-Cal
Medicare

Checklist and Instructions - Please submit your documents in this order

Required Documents for an Initial Licensure 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 (only applicable for CHOW) 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
HS 200 (PDF)	Licensure & Certification Application [Health and Safety Code (HSC) section 1212(a)] Tip Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions
Supporting Documents	A.10 – California Department of Health Care Access and Information (HCAI) [California Building Code section 1226 and HSC section 1226] and/or Certificate of Occupancy One of the two documents are required: Written certification: a California licensed architect or the local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements: California Building Code (CBC) California Fire Code (CFC) California Electrical Code (CEC) California Mechanical Code (CMC) California Plumbing Code (CPC) California Administrative Code (CAC) CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by a California licensed architect or local building authority Note: Title 24 compliance does not apply to CHOWs unless there has been construction and/or remodeling. If the facility is newly constructed or a remodeled building, submit the following: Submit a Certificate of Occupancy This is not applicable if there were alterations or repairs to existing buildings performed or conversion of space
Supporting Documents	Floor Plan Submit a floor plan that describes the requested change of service including a schematic of each room
Supporting Documents	B.3 – Internal Revenue Service Documentation [HSC section 1212(a)] 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–Non-Profit Status – Owner Type [HSC section 1212(a)] Submit a copy of the IRS Tax Exempt Determination Letter showing the non-profit 501(c)(3) status. (If Applicable)
Supporting Documents	B.3 – Organizational Chart – Owner Type [Title 42 Code of Federal Regulations (42 CFR) section 485.56] 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. 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.6
Supporting Documents	B.4.b – License Revocation (if applicable) [HSC section 1212(a)] Submit additional information, including all ownership and facility information, date and any final action
Supporting Documents	B.6 – Organizational Chart [42 CFR section 485.56] If the licensee is a subsidiary of another organization, include an organizational chart
Supporting Documents	D.1 – Control of Property [HSC section 1212(a)] Submit a copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed Licensee
CDPH 609 (PDF)	Bed or Service Request [HSC section 1204(b)(3)] Complete facility information and check the rehabilitation services the facility is requesting to provide
HS 215A (PDF)	Applicant Individual Information [HSC section 1212(a)] [42 CFR sections 455 Subpart B and 485.56] This form must be completed and signed for the following individuals: Administrator of the facility Medical Director Owners, directors, board members, corporate officers, LLC members/managers, and partners of the parent, grandparent, great grandparent, and etc. organization, if applicable Note: Corporate officers as defined in the By-Laws Each individual having a beneficial interest of exceeding five percent or more in the applicant organization and/or parent, grandparent, great grandparent, and etc. 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 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, 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 [HSC sections 1212(a), and (a)(6)] A resume is required for the Administrator, and Medical Director
Supporting Documents	Professional Licenses/ Certificates [HSC section 1212(a)(6)] An active registered medical license is required for the Medical Director Provide a printout of the current license from the Department of Consumer Affairs (https://search.dca.ca.gov/)
HS 309 1st Page (PDF)	Administrative Organization [HSC section 1212(a)] Along with the HS 309, the following supporting documents according to organizational type must be submitted:
Supporting Documents	Corporation [HSC section 1212(a)] Filing Statement from the Secretary of State (only if Articles of Incorporation are not endorsed by the CA Secretary of State) Articles of Incorporation (Endorsed by CA Secretary of State) By-Laws (Stating the size of boards) 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
Supporting Documents	Limited Liability Company (LLC) [HSC section 1212(a)] 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 [HSC section 1212(a)] Only complete fields that are applicable to applicant’s entity type Tip Page 2, item 1 — Health care districts will fill in the circle for other
Supporting Documents	Public Agency [HSC section 1212(a)] Copy of signed Resolution
Supporting Documents	Partnership [HSC section 1212(a)] Copy of signed Partnership Agreement
Supporting Documents	Out of State Corporations [HSC section 1212(a)] Copy of the Certificate of Qualifications from the CA Secretary of State allowing the applicant to do business in California
STD 850 (PDF)	Fire Safety Inspection Request [42 CFR section 485.62(a)(1)] The STD 850 form is required. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form. This form is not required for a CHOW unless there has been construction and/or remodeling. The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form. If the STD 850 form is NOT required for a particular MOBILE clinic, a written statement from the local fire authority agency must be submitted

Required Documents for Mobile Clinics Only

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
Housing & Community Development (HCD) Insignia	Department of Housing & Community Development (HCD) Insignia [HSC section 1765.120(b)] Department of Housing and Community Development (HCD) Approval Copy of HCD Inspection Approval, or Copy of HCD Insignia
Vehicle Registration	Copy of Vehicle Registration [HSC section 1765.120(a)] Submit copy of DMV registration documents, indicating: Vehicle Identification Number (VIN) Type of vehicle Manufacturer
Self-Contained Letter	Self-Contained Letter [HSC section 1765.150(b)] Submit a letter or statement on cover letter verifying the mobile unit is self-contained If the mobile unit is not self-contained, HCAI approval is only required if the utility hookups originate or pass through any general acute care hospital building
Local Planning/Zoning Approval	Local Planning / Zoning Approval [HSC section 1765.155(a)] Submit a copy of the Local Planning/Zoning approval If the Local Planning/Zoning approval is not required for a particular mobile clinic, CAB needs a written statement from the Local Planning/Zoning agency

Required Documents for a CHOW Only

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Supporting Documents

In addition to the forms required for an Initial application listed above submit the documents requested below: [HSC section 1212(a)]

Copy of Purchase Agreement or Operating Transfer Agreement
Interim Management Agreement (If applicable)
A letter from the prospective licensee (to CDPH) stating where the stored patient medical records will be maintained, and that the records will be made available to the previous licensee

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

Submit one copy of the HS 328 form with original signature

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 for the consolidated clinic on cover letter
Notarized signature page is required
Submit the “Acknowledgement” page from the notary public, if applicable

Medicare Certification Documents

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
CMS 1561 (PDF)	Notice – Effective Date of Provider Agreement Submit one copy of the HS 328 form with original signature
CMS 855B (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 for the consolidated clinic on cover letter Notarized signature page is required Submit the “Acknowledgement” page from the notary public, if applicable
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 359 (PDF)	Comprehensive Outpatient Rehab Facility Report Submit the comprehensive outpatient rehab facility report for certifications

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