Congregate Living Health Facility and Pediatric Day Health and Respite Care Facility
Report of Change Application Checklist for Change of Name
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 - Pālease submit your documents in this order
Required Documents for a Change the Name of The Facility or Licensee
Forms andāāā Supporting Documentsā
| āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
|
āCover Letter
| Cover Letter Letter on company letteārhead with the following information: - License number
- Facility name and address
- Indicate if the change of the name is for the Licensee and/or the Facility
- Facility ID number (if known)
- Brief description of request
- Previous and āproposed/new name
- 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)
- āāSignatureā
|
āHS 200 (PDF)
| Licensure & Certification Application
CLHF and PDHRC: [Title 22 of the California Code of Regulations (CCR) section 72201(b)(3) and 72211(a)]
CLHF: [Health and Safety Code (HSC) section 1267.13(n)]
PDHRC: [HSC section 1760.4(c)]
Page 1, section A, items 1(d) and 4(j) āā Indicate if the change of the name is for the Licensee and/or the Facility
Tip |
āSupporting Documents
| Board Resolution CLHF: [HSC 1265(i)] PDHRC: [HSC section 1762(a)]
Submit a copy of board resolution signed by officers and directors authorizing the facility name change and with the effective date.
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āSupporting Documents
| Articles of Incorporation CLHF: [HSC 1265(i)] PDHRC: [HSC section 1762(a)]
If the Licensee name or Corporate name changes, submit a copy of amended Articles of Incorporation filed with the CA Secretary of State.
Note: In case of entity conversion, submit a copy of conversion document filed with the CA Secretary of State
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