āForms and Supporting Documentsāā
| āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
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Cover Letter
| Cover Letterā
āLetter on company letterhead with the following informationā: ā - License number
- Facility name and address
- Facility ID number (if known)
- Brief description of request
- Contact information (naāme, 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)
- āSignature
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āHS 200 (PDF)
| Licensure & Certification Application CLHF and PDHRC: [Title 22 California Code of Regulations (CCR) sections 72201 and 72211(a)] CLHF: [Health and Safety Code (HSC) section 1267.13(n)] PDHRC: [HSC section 1760.4(c)]
Tip
- āPage 6, section B, item 6 ā An organization will have its own Federal tax ID numberā
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āSupporting Documentsāā
| āB.3 - Organizational Chart ā Owner Type
CLHF and PDHRC: [22 CCR section 72211(a)] CLHF: [HSC section 1267.13(n)] PDHRC: [HSC section 1760.4(c)]
Submit a before and after 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'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 ā see B.6
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āSupporting Documents
| āStock Purchase Agreement
CLHF and PDHRC: [22 CCR section 72211(a)] [HSC section 1265] CLHF: [HSC section 1267.13(n)] PDHRC: [HSC section 1760.4(c)]
Submit a copy of the signed Purchase Agreement.
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āHS 215A (PDF)ā
| āApplicant Individual Information
CLHF and PDHRC: [22 CCR section 72211(a)] CLHF: [HSC section 1267.13(n)] PDHRC: [HSC section 1760.4(c)]
This form must be completed and signed for the following individuals:
- New owners, directors, board members, corporate officers, LLC members/managers, and/or partners of the organization
- Each individual having a beneficial interest of five percent or more in the organization and/or parent organization
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
- āPage 7, Section F ā If answering yes to any question in this section, complete and attach the facility information sheet
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HS 215A Page 3 (PDF)
| 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
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HS 309 1st Pageā (PDF)
| Administrative Organization CLHF and PDHRC: [HSC section 1267.13(n) and 1760.4(c)] [22 CCR section 72211(a)]
Along with the HS 309, the following supporting documents according to organizational type must be submitted:
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Supporting Documentsā
| Corporation - Filing Statement from the Secretary of State
- Articles of Incorporation
- By-Laws
- Foreign (out-of-state) applicants submit a copy Certificate of Qualification from the California Secretary of State
- List of Board of Directors (only if additional space is needed to input all board of directors)
Tip - āPage 1, item 3 ā The incorporation date is located in the top right corner of the applicant Articles of Incorporationā
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Supporting Documentsā
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Limited Liability Company (LLC)ā - Filing Statement from the Secretary of State
- Articles of Organization
- Operating Agreement
- Foreign (out-of-state) applicants submit a copy Certificate of Qualification from the California Secretary of State
- List of Managing Members (only if additional space is needed to input all managing members) and managers who are not members
Tip
- Page 1, item 3 ā The organization date is located in the top right corner of the applicant Articles of Organization
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āHS 309 2nd Pageā (PDF)
| Organizational Structure Only complete fields that are applicable to applicant's entity type.
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āSupporting Documents
| Public Agencyā Copy of signed Resolution
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āSupporting Documents
| Partnership Copy of signed Partnership Agreement
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