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/post/california-health-alert-network-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(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

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 Service. The following must be completed for each facility and/or agency:​

• Facility name
• Facility address
• Type of facility
• Individual’s nature of involvement
• Individual’s dates of involvement
• Entity name
• ​Type of business entity (include EIN Number)

Stock Purchase Agreement

Submit a copy of the signed Purchase Agreement.

• 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

[HSC section 1575.7]

Submit this form with the names of the individuals in the roles 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