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

Skilled Nursing Facility and Intermediate Care Facility

Report of Change Application Checklist for Change of Governing Board

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.

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of Governing Board

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 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,1.5MB)	Licensure & Certification Application SNF: Title 22 of the California Code of Regulations (CCR) section 72211 ICF: 22 CCR section 73205 and 73225 Tips Page 6, section B, item 6 — An organization will have its own Federal tax ID number
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 Note: Submit the HS 215A form for each new individual Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating – see section B.6
HS 215A (PDF)	Applicant Individual Information SNF and ICF: 22 CCR section 72211 ICF: 22 CCR section 73225 This form must be completed and signed for the following individuals: New directors, board members, corporate officers, LLC members/managers, and partners of the applicant 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 and attach the facility information sheet
HS 215A Page 3 (PDF)	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
HS 309 Page 1 (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 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
Supporting Documents	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 Articles of Organization
Supporting Documents	New Board Member Verification Documentation verifying the appointment of new Board Member(s), such as copy of board meeting minutes, appointment letter, resolution etc.
HS 309 Page 2 (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

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