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

Chemical Dependency Recovery Hospital

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)

Checklist and Instructions - Please submit your documents in this order

Required Documents for an Initial License 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 ID number (if known) Brief description of request Location Information 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)	Licensure & Certification Application [Health and Safety Code (HSC) section 1250.3 and 1254.2] [Title 22 California Code of Regulations (CCR) section 79101] Tips: Page 6, Section 6 — An organization must own 100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN) Page 9, Section 5 — When listing the names of individuals with direct or indirect ownership of the facility in Section 5, provide the EIN (do not enter a Social Security number in this field)
Supporting Documents	A.10 - Construction [22 CCR section 79105] Submit evidence of compliance with local building code requirements whether or not construction occurred
Supporting Documents	B.3 - Organizational Chart - Owner Type Submit an organizational chart if the owner is a profit, 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	D.1 - Control of Property Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee
Supporting Documents	E. Management Company Agreement (If applicable) Facilities operated under a Management Agreement between the licensee and management company must complete and submit Attachment E-1 (Management Company Information) on HS200 along with a copy of the Management Agreement. The Management Agreement must state that the licensee is responsible for the facility
CDPH 609 (PDF)	Bed or Service Request For new facilities or initial licensure, complete the columns marked “Requested Beds" and “Requested Services" For currently licensed facilities or Change of Ownership complete the columns marked “Existing Beds" and “Existing Services" and the columns marked “Requested Beds" and “Requested Services" For CHOW applications, the information marked in the “Existing" and “Requested" fields must be the same.
Supporting Documents	Written Listing of Services [22 CCR section 79101(d) and 79251] Submit a detailed written listing of those services to be offered or provided by the hospital. The detailed written listing shall include but not be limited to: Age range of patients for whom care will be provided. Classifications of chemical dependencies to be treated. Descriptions of each of the specific elements of the overall treatment program. All proposed modifications to existing approved treatment programs. Note: In addition to the basic services as specified in Title 22 CCR sections 79201 through 79221, a chemical dependency recovery hospital may be approved by the Department to provide one or more of the following optional supplemental services: Medical detoxification Treatment programs for adolescents who have a chemical dependency Any other services which are provided for the treatment of chemical dependency, but are not addressed in regulations shall have the prior approval of the Department
CDPH 709 (PDF)	Client Accomodation Analysis Complete this form in its entirety Must be signed
Supporting Documents	Floor Plan Submit a floor plan that coincides with the room schematics on the CDPH 709
HS 215A (PDF)	Applicant Individual Information [HSC section 1265.1] This form must be completed and signed for the following individuals: Administrator and Medical Director 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 exceeding 10 percent or more in the applicant organization and/or parent organization Tips Page 2, Section B.3 — 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 D; however, the resume must contain all required information included in Section D Page 7, Section F — If answering yes to any question in this section, complete and attach the 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 [22 CCR section 79309(a) and 79301] A resume is required for the Medical Director and Administrator If the Medical Director also serves as the Administrator only one resume is needed
HS 309 1st Page (PDF)	Administrative Organization Along with the HS 309, depending on the organizational type, the following supporting documents 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 applicant 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 2nd Page (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
HS 400 (PDF)	Affadavit Regarding Patient Money [22 CCR section 79119(b)] Mark either A or B box. If B is checked, enter the amount of patient monies managed and submit the bond required on form HS 402 Note: HS 400 is only required when applicable
HS 402 (PDF)	Surety Bond Verification [22 CCR section 79119] Chemical Dependency Recovery Hospitals which handle $25.00 or more per patient or $500.00 or more for all patients within any one month, shall post a bond in accordance with the amounts listed on the HS 400 Affidavit Regarding Patient Money Note: HS 402 only required when applicable
HS 602 (PDF)	Transfer Agreement [22 CCR section 79319] CDRH shall have current written transfer agreement(s) with one or more general acute care hospitals for the provision of acute medical services.
STD 850 (PDF)	Fire Safety Inspection Request [22 CCR section 79105] The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. Note: This form is NOT required for a CHOW

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: [22 CCR section 79351 and 79353]

Copy of Purchase Agreement or Operating Transfer Agreement
A letter from the prospective license to CDPH stating where the stored patient medical records will be maintained, and that the records will be made available to the previous licensee
When applicable, written verification (with amount) by a public accountant, of all patients' monies which are being transferred to the custody of the new owners shall be obtained by the new owner in exchange for a signed receipt

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