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 ​

​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

​​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
• If part of a chain, a diagram indicating the relationship between the applicant and the persons or entities that are part of the chain and the name, address, and license number, if applicable, for each person or entity in the diagram. [HSC 1253.39(c)(10)(B)]​

SNF: HSC section 1265

Facilities operated under a management agreement between the licensee and a management company must complete and submit Attachment E-1 (Management Company Information) and submit a copy of the management agreement

• The management agreement must state that the licensee is responsible for the skilled nursing facility 

SNF: HSC sections 1253.3 and 1265

This form must be completed for the following individuals:

• 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 — 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 4, Section D – 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 D
• Page 5, Section E – If answering yes to any question in this section, complete and attach the facility information sheet​

Administrative Organization

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
• LLC Operating Agreement
• List of Managing Members (only if additional space is needed to input all managing members)
  

Tip

• Page 1, item 3 — The incorporation date is located in the top right corner of the Articles of Organization
• Ensure the operating agreement identifies the Capital Contributions, which lists each individual and/or entity that is contributing to the LLC
  

Public Agency

Copy of signed Resolution

Transfer Agreement

SNF: HSC section 1760.4 and 22 CCR section 72519

Copy of current written or proposed transfer agreement with a General Acute Care Hospital 

Tip

• The facility may not have a Facility Provider Number yet, and may be left blank
  

Notice - Effective Date of Provider Agreement

If applying for both Medi-Cal and Medicare certification, only submit one copy of this form

Long Term Care Facility Application for Medicare & Medicaid

Note:  F14 – if a parent company was identified on the HS 200, B.6., enter the same name here

• 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