State of California ­ Health and Human Services Agency California Department of Public Health Licensing and Certification District: FOR DEPARTMENTAL USE ONLY ELMS Facility Number: Proposed name of facility/agency/clinic: APPLICANT INDIVIDUAL INFORMATION This form is intended for any individual owning the applicant facility or for any individual involved (now or in the past) with any health or community care facility. Refer to the INSTRUCTION SHEET to see who needs to complete this form. This HS 215A form needs to be completed as part of an application package plus it needs to be completed for disclosure purposes when changes are reported in officers, directors, purchase of stock, etc., as required by law, even though no change in legal ownership is occurring. A. Identifying Information Name Business address (number, street, apartment/suite number or letter if applicable) Title in relation to this facility Have you applied for ANY license for a health facility or community care facility using any name other than your true full name? If yes, list all other names. If an Administrator for proposed clinic, list hours that will be spent at the clinic each week. If an Administrator at more than one licensed clinic, list the name of each clinic and the number of hours spent in each licensed clinic per week. Date of Birth City, State, & Zip B. Criminal Record 1. Have you ever been convicted of an offense that is still on your record, whether misdemeanor or felony? 2. Has there been a judgment against you for Medicare or Medicaid (Medi-Cal) fraud or by a health care professional/technical licensing entity? Yes No Yes No If yes to questions 1 or 2 above, please explain and provide dates and conviction information (attach additional pages if necessary): C. Professional Licenses/Certificates ­ This requirement is mandatory for Primary Care Clinics and optional for Health facilities. TYPE PERIOD HELD ISSUING AGENCY HS 215A (2/08) 1 American LegalNet, Inc. www.FormsWorkflow.com State of California ­ Health and Human Services Agency California Department of Public Health Licensing and Certification D. Employment/Business Summary (for last 10 years). Please list any additional experience that qualifies you to operate this type of facility. Begin with your most recent job. Attach additional pages if necessary. Name and address of employer From: To: From: To: From: To: From: To: Job title E. Facility, Agency, Clinic Involvement (in or out of California) The questions below are for "individuals" and do not pertain to the facility that is applying for licensure. 1. Have you ever been involved with a business entity that operated a health facility or community care facility? No If YES, complete Section F (below) and the "Facility Information Sheet" (attached). Yes Have you ever operated or managed (including management agreements) any of the following facility types? No If YES, complete Section F (below) and the "Facility Information Sheet" (attached). Yes Adult Day Health Care Center Clinics COMMUNITY CARE FACILITY General Acute Care Hospital Health Facility Home Health Agency Hospice ICF/DD ICF/DD-H ICF-DD-N Intermediate Care Facility Pediatric Day Health & Respite Care Residential Care Facility for the Elderly Skilled Nursing Facility Other 2. 3. Have you ever held a 5 percent or more beneficial ownership interest in any of the facility types above? Yes No If YES, complete Section F (below) and the "Facility Information Sheet" (attached). F. Adverse Actions Have you been affiliated with any facility, either past or present, that has been identified as having one or more of the No If YES, check all applicable: Yes following adverse actions? Receiver appointed Had a final Medi-Cal decertification action taken Placed on probation Suspension Resolved by settlement Revocation action filed Revoked (whether stayed or not) If yes, please explain (including facility name and address). Attach additional pages if necessary: I declare under penalty of perjury that the statements on this form and any accompanying attachments are correct to the best of my knowledge. Signature: Date: RELEASE OF INFORMATION STATEMENT The information provided on this form is mandatory and is necessary for licensure approval. It will be used to determine individual applicant's or applicant facility's ability to provide health services. The information is requested by the California Department of Public Health, Licensing and Certification, in accordance with the Health and Safety Code. Failure to provide the information as requested may result in nonissuance of a license or license revocation. The information is considered public information and will be made available to the public upon request. The information shall be included and maintained in the individual facility's public files located in Licensing and Certification district offices. HS 215A (2/08) 2 American LegalNet, Inc. www.FormsWorkflow.com State of California ­ Health and Human Services Agency California Department of Public Health Licensing and Certification FACILITY INFORMATION SHEET You are required to complete the following for each facility (including all facilities in all business entities) with which you have a current relationship or have had a past relationship (going back 3 years). Refer to the INSTRUCTION SHEET. Facility name: Type of Facility Adult Day Health Care Center Clinic COMMUNITY CARE FACILITY General Acute Care Hospital Health Facility HHA Hospice ICF ICF/DD ICF/DD-H ICF/DD-N ICF Residential Care for the Elderly SNF OTHER FACILITY TYPE (explain): Facility address (number, street, city): "Type" of Business Entity For EACH business entity, identify the name & EIN of the entity: Corporation: Individual: LLC: Management Company: Partnership: OTHER Business Entity (explain): Are any of the above Business Entities a "PARENT" organization to the applicant facility? If Yes, explain. Yes No State: Zip code: Individual's "Nature" of Involvement Administrator of Clinic, SNF or ICF Agent Director Licensee Manager of "parent" organization Managing employee of a HHA Member Officer of corporation Owner Partner Sole Proprietorship Stockholder -- Ownership %: Trustee OTHER Nature of Involvement (explain): Dates of involvement: From: To: Facility name: Type of Facility Adult Day Health Care Center Clinic COMMUNITY CARE FACILITY General Acute Care Hospital Health Facility HHA Hospice ICF ICF/DD ICF/DD-H ICF/DD-N ICF Residential Care for the Elderly SNF OTHER FACILI