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

Surgical Clinic/Ambulatory Surgery Center

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/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 [Health and Safety Code (HSC) section 1212] 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	B.3 – Organizational Chart – Owner Type [HSC section 1212] 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 entity Applicant's direct and indirect owners with 10 percent or more ownership interest in the applicant entity (include ownership percentages) Officers and directors of applicant and any entity with 10 percent or more ownership interest in the applicant Note: Submit the HS 215A form for each of these individuals Management company, if applicable Owners, officers, and directors All other licensed and/or certified facilities operated by applicant's parent company and/or management company, if applicable
HS 215A (PDF)	Applicant Individual Information [Title 42 Code of Federal Regulations (CFR) section 455 subpart B and 420 subpart C] [HSC section 1212] The form must be completed and signed for the following individual(s): Applicant Organization Owners, directors, board members, corporate officers, LLC members/managers, partners, and/or trustees of the applicant organization and/or Management Company Individual direct and indirect owners with 10 percent or more ownership interest in the applicant entity Officers and directors of applicant and any entities with 10 percent or more ownership interest in the applicant Tips Section B – List applicant's legal name, nature of involvement to the facility, date of birth, driver's license or state-issued identification number and expiration date, social security number 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 Section F — If answering yes to any question in this section, complete and attach the facility information sheet (section H)
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
HS 309 Page 1 (PDF)	Administrative Organization [HSC section 1212] 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 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 Articles of Incorporation
Supporting Documents	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)
HS 309 Page 2 (PDF)	Organizational Structure 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 Copy of signed Resolution
Supporting Documents	Partnership Copy of signed Partnership Agreement

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