Cover Letter

Letter on company letterhead with the following information:

• License number
• Facility name and address
• Facility ID number (if known)
• Brief description of request
• 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
  

ICF/DD: 22 CCR section 76205(a)(10)

Submit a before and after 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

ICF/DD: 22 CCR section 76203

ICF/DD-H: 22 CCR section 76844 and 76851(a)(2)

This form must be completed for the following individuals:

• New owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization 
• Each new individual having a beneficial interest of exceeding ten percent or more in the applicant organization and/or parent organization
  

• Page 2, section B — 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 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, complete and attach the facility information sheet

Administrative Organization

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
• 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) 
  

• Page 1, item 3 — The organization date is located in the top right corner of the applicant Articles of Organization​
  

Public Agency​

Copy of signed Resolution

Transmittal Application for Criminal Background Investigation

[HSC sections 1575.7(a)(1) and 1575.7(a)(2)]

Mail this form to the address indicated on the form only for the new individuals below:

• Owners
• Directors
• Board Members
• Corporate Officers
• LLC Members/Managers
• Partners
• Individuals having a beneficial interest exceeding 5% or more in the applicant organization and/or parent organization

Submit this form to CDPH Criminal Background Section (address is listed on the form).