​​Additional Instructions

(​​​Each form listed also has instructions on the form)​

Licensure & Certification Application

[Health and Safety Code (HSC) section 1267.13(n)] [Title 22 California Code of Regulations (CCR) section 72201]

Tips

• Page 6, section B, item 6 —This parent company will have its own Employer Identification Number (EIN)
• Page 10, section C, Item 9 - Select which of the following services will be provided:
• CLHF A: Services for individuals, who are mentally alert, physically disabled individuals who may be ventilator dependent
• CLHF B: Services for individuals who have a diagnosis of terminal illness, a diagnosis of a life-threatening illness; or both
• CLHF C: Services for individuals who are catastrophically and severely disabled. Services offered to a catastrophically disabled person shall include, but not be limited to speech, physical, and occupational therapy
  

A.10 - Construction

[HSC section 1267.19]

For Initial, submit one of the following regardless if construction occurred or not:

• Evidence of compliance with local building code requirements or;
• Certificate of Occupancy issued by the local building authority
  

[HSC section 1267.13(n)] [22 CCR section 72201]​

Submit an organizational chart if the owner is a 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

[HSC section 1267.13(n)(o)] [22 CCR section 72201 and 72513(a)(1)]

This form must be completed for the following individuals and include signatures and dates:

• Administrator of the facility
• Owners, directors, board members, corporate officers, LLC members/managers, and partners of the organization and/or Management Company
• Each individual having a beneficial interest of five percent or more in the organization and/or parent organization

Tips

• Page 2, section B, Item 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 term 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, must complete section H for the Facility Information Sheet

Administrative Organization

[HSC section 1267.13(n)] [22 CCR section 72201]​

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
• Operating Agreement
• List of Managing Members (only if additional space is needed to input all managing members) and managers who are not members
  

Public Agency

Copy of signed Resolution

[HSC sections 1267.13(n) and 1318] [22 CCR section 72217]

• 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
• If handling less than $500 for all patients in any one month, a bond is not required.

Transfer Agreement

[HSC section 1267.13(n)] [22 CCR section 72519]​

Copy of current written transfer agreement with a hospital.

• May submit a CDPH 5000 Program Flex if Transfer Agreement cannot be obtained.
  

Tips

• The facility administrator may sign this form
  
• ​The facility may not have a provider number yet and this line may be left blank​

Fire Safety Inspection Request (not applicable for a CHOW unless there is construction)

[HSC section  1267.13 (a)(b)] [22 CCR section 72505]

The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The OSHPD Fire Life & Safety (FLS) Inspection approval does not replace this form