āForms and Supportingā Documentsā
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āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
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āCover Letter
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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
- Attestation that the applicant provider is located in proximity, in time and distance, to a facility with the capacity for management of obstetrical and neonatal emergencies, including the ability to provide cesarean section delivery, within 30 minutes from time of diagnosis of the emergency. Include the facility name and address with the capacity for management of obstetrical and neonatal emergencies [Health and Safety Code (HSC) section 1204.3(4)(A)]
- 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)
- Signatureā
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āHS 200 (PDF)
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Licensure & Certification Application
[HSC Section 1212(a)]
Tip
- āAttachment F-1 ā 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
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āSupporting Documents
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A.10 ā
California Department of Health Care Access and Information (HCAI) [California Building Code section 1226 and Health and Safety Code (HSC) section 1226]
And/ Or Certificate of Occupancy
One
of
the two documents are required:
-
āWritten
certification:
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)
Note:
Title 24 compliance does not apply to CHOWs unless there has been construction and/or remodeling If
construction
occurred
and
if
the
construction
resulted
in a new building or addition:
-
Submit a
Certificate
of
Occupancy
-
This is not applicable if there were alterations or repairs to existing buildings performed or conversion of spaceā
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āSupporting Documents
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āB.1
ā
Licensee Nameā
The licenseeās formal organization name must be consistent throughout all documents
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āSupporting Documents
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āB.3 - Organizational Chart
[HSC section 1212(a)]ā
Submit an organization chart/flow chart if the owner is a profit or nonprofit corporation, limited liability company (LLC), or general partnership. The organization chart needs to display the following:
- Applicantās owners, directors, board members, corporate officers, LLC members/managers, and 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 ā see B.6
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āSupporting Documents
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āB.3
ā
Internal Revenue Service Documentation
[HSC section 1212(a)]
Submit one of the following IRS tax documents showing entityās legal name and Tax Identification Number:
- āForm 941- Employerās Quarterly (Federal Tax Return)
- Form
8109-
C
(FTD
Address Change)
- Letter
147-C
(EIN
Confirmation
Notification)
- Form
SS-4
(Confirmation
Notification)ā
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Supporting Documents
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B.3 ā Non Profit Status ā 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)ā
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Supporting Documents
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āB.4.a
ā
Licenseeās āOtherā Facility Involvement
Answer all aspects of the question
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āSupporting Documents
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B.4.b ā License Revocation (if applicable)
[HSC section 1212(a)]
Submit additional information, including all ownership and facility information, date and any final action
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āSupporting Documents
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āāāB.6
ā
Organizational Chart
[HSC section 1212(a]
If there is a āsubsidiaryā (parent company) submit:
- An organization chart with the parent company name
- A listing of all owners, directors, board members, corporate officers, LLC members/managers, and partners of the parent company
Note: Submit the HS 215A form for each of these individuals
- A listing of all facilities the parent company is operating
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āSupporting Documents
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āC.2.a
ā
Name of āCurrent Agencyā
Note: If CHOW, enter current facility name
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Supporting Documentsā
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āC.3.a ā Name of āProposedā Agencyā
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Supporting Documentsā
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āC.4.a
ā
Administrator
[HSC section 1212(a)]
Submit the HS 215A form for the administrator of the facility
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āSupporting Documents
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āC.5 ā
Ownership
[HSC section 1212(a)]ā
-
āList
all
individuals
having
5%
or
more
ownership,
unless
ānonprofit.ā
- Submit
the
HS
215A
form
for
each
of
these
individuals
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āSupporting Documents
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āD.1
ā 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
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āSupporting Documents
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āG.1 ā
Signatureā
Signature is required and must be signed by the applicant (not the administrator unless the owner is the administrator)
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āHS 215A (PDF)ā
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āApplicant Individual Information
[HSC Section 1212(a)]
This form must be completed and signed for the following individuals:
- Administrator of the facility
- 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 5% or more in the applicant organization and/or parent organization [HSC Section 1212(a)]
- Signature is required
Tips
- Page 2, section B ā 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 ā 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 ā If answering yes to any question in this section, complete Section H: 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 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)
- Individualās nature of involvement
- Individualās dates of involvement
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āSupporting Documents
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Resume
[HSC section 1212(a)]
A resume is required for the Administrator
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HS 309 1st Pageā (PDF)
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Administrative Organization
[HSC 1212(a)]
Along with the HS 309, the following supporting documents according to organizational type must be submitted:
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Supporting Documentsā
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āCorporationā
- Filing Statement from the Secretary of State (only required 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 board)
- List of Board of Directors (only if additional space is needed to input all board of directors)
āNote:
Submit the HS 215A form for each individual listed as a board of director
Tips
- Page 1, item 2 ā The Administrator of Corporation LLC is usually the CEO/President
- Page 1, item 3 ā The incorporation date is located in the top right corner of the applicant Articles of Incorporation
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Supporting Documentsā
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Limited Liability Company (LLC)
- Filing Statement from the Secretary of State (only required if Articles of Organization are not endorsed by the CA Secretary of State)
- Articles of Organization (endorsed by CA Secretary of State)
- Operating Agreement
- List of members, holders, officers, managers (only if additional space is needed to input all managing members)
Note: Submit the HS 215A form for each individual listed as a member, holder, officer, or manager
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Supporting Documents ā
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āGoverning Board of Directors
- Enter
the
number
of
members/managers
- Submit
the
HS
215A
form
for
each
individual
listed
under this item
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āHS 309 2nd Pageā (PDF)
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Organizational Structure
[HSC section 1212(a)]
Only complete fields that are applicable to applicantās entity type
Tipā
- Page 2, item 1 ā For California Out-of-State Corporations, LLCs, etc. submit a copy of the Certificate of Qualification from the California Secretary of State
- Page 2, item 5 ā Must be completed for Corporations, LLCS, and Partnerships
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āSupporting Documents
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Public Agency
Submit a copy of signed Resolution
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āSupporting Documents
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āPartnershipā
- Copy of signed Partnership Agreement
- Copy of the California Secretary of State filing, if applicable
- HS 215A form for each partner
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STD 850 (PDF)
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Fire Safety Inspection Request
[HSC section 1212(a)]
The STD 850 form must be submitted or a similar form from the local fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form
Note: This form is not required for a CHOW unless there has been construction and/or remodeling. ā
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āDHCS 1051ā (PDF)
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āCivil Rights Compliance Reviewā
Send directly to the Office of Civil Rights - address is on the last page of the formā
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