ATTACHMENT E-1 MANAGEMENT COMPANY INFORMATION ONLY FOR SNF's or ICF's 1. Submit a copy of the Management Agreement with this application. Name of management company: Address (number & street): City, State, & Zip: EIN: Name of facility to be managed: Address (number & street): City, State, & Zip: EIN: 2. Provide the following information for each individual having a 5 percent or more interest in the management company. Submit an attachment for additional names that includes all of the required information listed below. (1) Individual’s name: Address (number & street): City, State, & Zip: % Owner: (2) Individual’s name: Address (number & street): City, State, & Zip: % Owner: (3) Individual’s name: Address (number & street): City, State, & Zip: % Owner: (4) Individual’s name: Address (number & street): City, State, & Zip: % Owner: 3. Provide a list of all facilities, agencies, or clinics with which you have entered into a management agreement. Submit an attachment for additional facility, agency, or clinic names that includes all of the required information listed below. (1) Facility, agency, or clinic name: Address (number & street): City, State, & Zip: Dates of involvement: (2) Facility, agency, or clinic name: Address (number & street): City, State, & Zip: Dates of involvement: (3) Facility, agency, or clinic name: Address (number & street): City, State, & Zip: Dates of involvement: (4) Facility, agency, or clinic name: Address (number & street): City, State, & Zip: Dates of involvement: HS 200 (07/06) 5 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS SNF or ICF Management Company Application: See Attachment E-1 below. Type or print clearly. Return original and maintain a copy for your records. The Licensee's name must be consistent throughout all documents submitted. Submit all supplemental paperwork requested to complete your application. Do not leave items blank. If not applicable, mark N/A. A. APPLICATION INFORMATION 1. Type of application: select items a, b, c, or d. If b is selected, provide effective date of change in number 2. If c is selected, complete Sections C1-5; F, and Attachment E-1. If d is selected you must select an option in number 4 -- “Type of Change.” 2. Provide actual date applicant took charge of the financial management of facility. This date is used to show effective date of the ownership change for certification purposes only. 3. Amount of fee enclosed: enter the amount of money enclosed with this application. If no fee is required, enter “N/A”. (Refer to fee schedule for appropriate fee requirements.) 4. Type of change: check all that apply. 5. Type of facility, agency, or clinic: select the appropriate category. 6. (a) Check “yes” if requesting certification for Medicare. ICF/DD, ICF/DD-N, ICF/DD-H facilities and primary care clinics that are not certified as rural health clinics are not eligible for Medicare. (b) If “yes” to item 6(a), provide name of fiscal intermediary under item 6(b). 7. Check “yes” if requesting participation in Medi-Cal (Medicaid). 8. (a) Current facility bed capacity: enter the total number of persons for whom care can currently be provided in any 24-hour period. This figure must agree with the “Certificate of Occupancy”. (b) Proposed facility bed capacity: enter the proposed total number of persons for whom care will be provided in any 24-hour period. 9. Enter age range of persons to receive/receiving care. 10. Enter days and hours of facility operation. 11. Enter date construction is to begin, and date construction is to be completed (not applicable for ICF/DD, ICF/DD-N, ICF/DD-H facilities). Submit a copy of the form “Construction Advisory Board” (form OSH-FDD 377(11/97)) if OSHPD has approved construction. Submit a copy of the above form to the local district office prior to the survey if OSHPD has not yet approved construction. B. LICENSEE INFORMATION 1. Licensee name: enter the full legal organization name (LLC, partnership, and corporation) or individual(s) responsible for the facility/agency. If “Inc.” is included in your legal name, it must appear in the name. Individuals enter first, middle, and last name. Husband and wife, if joint applicants, must both be listed. NOTE: All individuals including owners, partners, principal officers of corporations/LLCs, members, managers, and administrators (clinics only) must complete “Applicant Individual Information” (HS 215A). 2. 3. HS 200 (07/06) Enter the federal employer’s tax ID number. Owner Type: select one of the options and then: Submit an organizational chart, for items b, c, d, or e showing entity, persons, facilities, and tax EIN numbers. Submit a copy of the Internal Revenue Service and Franchise Tax Board letters of determination of nonprofit status, if item c, “nonprofit corporation” is selected, and the facility is a primary care Clinic. 6 American LegalNet, Inc. www.FormsWorkflow.com 4. 5. 6. Licensee address: enter address of legal organization (LLC, corporation, partnership) or individual(s) responsible for the facility, agency, or clinic. Provide phone number with area code, fax number, and e-mail address. Other Facilities: (a) Identify all other facilities, agencies, or clinics the licensee (LLC, corporation, partnership, individual) has been involved in, both in and outside of California. Submit an attachment, if needed, for additional entities, which includes the facility, agency or clinic type (including “affiliate” clinics), name, address, nature of involvement, and dates of involvement. This attachment must include all of the required information listed. Submit an attachment, if needed, for any entity identified in number 5a, which has had a license revocation action filed, license placed on probation, suspended, or revoked (whether stayed or not) or, for SNFs and ICFs, resolved by settlement, receiver appointed, or has a final Medi-Cal decertification action taken. Include all ownership and facility information, dates, and any final action. Subsidiary: check “yes” if the licensee is a subsidiary of another organization and complete the information requested. Submit a detailed organizational chart, including parent and all subsidiary information, and federal tax ID numbers. C. FACILITY, AGENCY, OR CLINIC INFORMATION 1. Management Agreement: (a) Check “yes” if the facility, agency, or clinic is going to be operated under a management contract/agreement, between the proposed owner and a management company. Proceed to Section “E” (below). (b) Check “yes” if there is an “interim” management agreement, between the proposed owner and the current owner, to run the facility until the change of ownership is completed. Submit a copy of the “interim” management agreement, if applicable. 2. Facility, agency, or clinic name: Enter the name used to designate the single facility, agency or clinic under the license being requested. Also, provide the current facility, agency, or clinic name, and current license number (if different). Change of ownership usually results in a name change. 3. Provide facility, agency, or clinic address, including phone number with area code, fax number, and e-mail. 4. Provide facility, agency, or clinic mailing address, if different from number 3 (above). 5. Provide the name and title of the individual to be in charge of the facility, agency, or clinic as well as any professional license number (if applicable). 6. Administrator: (a) Provide the name of the facility administrator, date of hire, license number, and license expiration date. (b) Provide the name of the director of nursing services (if applicable), date of hire, license number, and license expiration date. 7. Provide name(s) of all individuals having a 5 percent or more interest in the ownership of this facility, if applying for SNF or ICF licensure. For all other facility, agency, or clinic types, provide the name(s) of those having 10 percent or more interest in the ownership. Specify how these persons are related to one another as spouse, parent, child or sibling. Submit an attachment for all additional names. This attachment must include all of the required information. 8. Financial Resources: Only applies to SNF, ICF, and ICF/DD: Submit evidence, satisfactory to the Department, that the licensee has sufficient financial resources to operate the facility for at least 45 days (bank statement, certificate of deposit etc.). The amount is determined by multiplying 45 days X number of beds X rate. 9. Over-concentration -- Only applies to ICF/DD, ICF/DD-H and ICF/DD-N: (a) Are there other ICF/DD, ICF/DD-H, ICF/DD-N residential care, pediatric day health, or respite care facilities within 300 feet of this facility? Check “yes”, “don't know” or “no”. (b) Are there any congregate living health facilities within 1,000 feet of this facility? Check “yes”, “don’t know” or “no”. HS 200 (07/06) 7 American LegalNet, Inc. www.FormsWorkflow.com 10. Program Plan -- Only applies to ICF/DD, ICF/DD-H and ICF/DD-N: Indicate if the program plan has been approved by the Department of Developmental Services. The “current licensee” can grant permission for their Program Plan to be used for 6 months if a letter is submitted to CDHS. If “no” is checked, the application package will be held until a copy of the approved program plan letter is received. Submit a letter to CDHS from the “current” licensee that the “proposed” licensee has their permission to use the “current” licensee’s Program Plan for up to 6 months, if applicable. Submit a copy of the Program Plan approval letter, if “yes”. D. PROPERTY INFORMATION 1. Licensee must show evidence of control of property. Submit a copy of the deed and/or bill of sale, if property is owned. Submit a copy of the rental agreement, if property is rented. Submit a copy of the lease agreement, if property is leased. Submit a copy of the original lease plus a copy of the sublease, if property is subleased. Submit appropriate evidence if “other” is checked. 2. Provide name and address of the Owner of Record, Lessee and Sub-lessee as applicable. E. MANAGEMENT COMPANY INFORMATION (Complete Sections A1, C1-5, F & ATTACHMENT E-1) F. STATEMENT OF RESPONSIBILITIES Application must be signed by licensee or authorized representative. ATTACHMENT E-1 MANAGEMENT COMPANY INFORMATION ONLY FOR SNF's OR ICF's 1. If the proposed facility, agency, or clinic will be operated by a management company, under a management contract between the proposed owner and a management company, provide the name, address, and federal tax ID number of Management Company and name of facility to be managed. Submit a copy of the Management Agreement. 2. Provide the name, address, and percent of ownership for each person having a 5 percent or more interest in the Management Company. Submit an attachment for additional names. This attachment must include all of the required information. 3. Provide a list of all facilities, agencies, or clinics that you have contracted to manage. Submit an attachment for additional facilities, agencies, or clinics. This attachment must include all of the required information. HS 200 (07/06) 8 American LegalNet, Inc. www.FormsWorkflow.com