State of California ­ Health and Human Services Agency California Department of Public Health Licensing and Certification LICENSURE & CERTIFICATION APPLICATION District: FOR DEPARTMENTAL USE ONLY ELMS Facility Number: Proposed name of facility/agency/clinic: A. APPLICATION INFORMATION 1. Type of application (check one): a. Initial b. Change of Ownership (see #2 below) c. Management company (see Sections C1-5, F, and Attachment E-1) d. Other change (see Section A4): 2. Change of Ownership Only - For Certification Purposes: We wish to make certain that our records correctly show the effective date of the ownership change for certification. This date should reflect the actual date on which you took charge of the financial management of the facility rather than the date of sale or date of state license change. Effective date of change: 3. Amount of fee enclosed: $ 4. Type of Change (check all that apply): a. Not applicable b. Change of capacity (see # 8 below) c. Change of location d. Change of services e. Change of facility type 5. Type of facility, agency, or clinic (check one) a. Skilled Nursing Facility (SNF) b. Intermediate Care Facility (ICF) c. ICF/Developmentally Disabled (ICF/DD) d. ICF/DD-Habilitative (ICF/DD-H) e. ICF/DD-Nursing (ICF/DD-N) f. Primary care clinic ­ Free g. Primary care clinic ­ Community h. Surgical clinic f. Change of bed classification g. Change of name h. Construction of new or replacement facility i. Stock transfer j. Other (specify) i. j. k. l. m. n. o. Rural health clinic (for Certification "only") General acute care hospital Adult day health care center Home Health Agency (HHA) Hospice Chronic dialysis clinic Other (specify) 6. a. Do you wish to apply for the Medicare program? b. Fiscal Intermediary choice: Yes No Medicare Provider #: 7. Do you wish to apply for the Medi-Cal (Medicaid) program? 8. a. Current facility bed capacity: b. Proposed facility bed capacity: 9. Age range of clients: 10. Days and hours of operation: Yes No 11. Is construction required? Yes No If "yes", submit copy of "OSHPD" form (see instructions on page 6) If "yes", date construction to begin: If "yes", date construction to be completed: HS 200 (02/08) 1 American LegalNet, Inc. www.FormsWorkflow.com B. LICENSEE INFORMATION 1. Licensee name: 2. Federal employer's tax ID number: 3. Owner type (check one): Submit organizational chart for b, c, d, and e. a. Sole proprietorship (Individual) g. City b. Profit corporation h. County c. Nonprofit corporation i. State agency d. Limited Liability Company (LLC) j. Other agency (specify) e. Partnership ­ General k. Public agency (specify) f. Partnership ­ Limited 4. Licensee address (number & street): City, State, & Zip: E-Mail: Telephone number: Fax number: 5. a. Identify other facilities, agencies, or clinics the licensee has been licensed for, operated, managed, held a 5% or more interest in, or served as a director or officer. Include facilities both in and outside of California. Submit an attachment for additional facilities that includes all of the required information listed below. (1) Facility Name: Facility address (number & street): Facility Type: City, State, & Zip: (2) Facility Name: Facility address (number & street): Facility Type: City, State, & Zip: (3) Facility Name: Facility address (number & street): Facility Type: City, State, & Zip: (4) Facility Name: Facility address (number & street): Facility Type: City, State, & Zip: b. If any facility, agency, or clinic identified in 5.a. has had a license revocation action filed, license placed on probation, suspended, or revoked (whether stayed or not) or, for agency or clinic resolved by settlement, receiver appointed, or had a final Medi-Cal decertification action taken, please submit additional information, including all ownership and facility information, date and any final action. 6. Is the licensee a subsidiary of another organization? Yes If "yes", complete the information below and submit an organizational chart: Parent organization name: Parent federal tax ID Number: P.O. Box or number & street: City, State, & Zip: No HS 200 (02/08) 2 American LegalNet, Inc. www.FormsWorkflow.com C. FACILITY, AGENCY OR CLINIC INFORMATION Management Agreement (this only applies to SNF's & ICF's): 1. a. Is the facility, agency, or clinic going to be operated under a management contract/agreement between the proposed owner and a management company? If "yes", proceed to Section E (below). b. Is there an "interim" management agreement, between the proposed owner and the current owner, to run the facility, agency, or clinic until the change of ownership is completed? If "yes", submit a copy of the "interim" management agreement. 2. Name of "proposed" facility, agency, or clinic: Current facility, agency, or clinic name (if change of ownership): Facility license number: 3. Address (number & street) of "proposed" facility, agency, or clinic: City, State, & Zip: 4. Mailing address, if different from above: Number & Street: Fax number: City, State, & Zip: 5. Name of person to be in charge of facility, agency, or clinic: Title: Professional License number: 6. a. Name of administrator: Professional License number: b. Name of director of nursing: Professional License number: Date of hire: Expiration date: Date of hire: Expiration date: Telephone number: E-mail address: Telephone number: Yes No Yes No 7. List persons having 5 percent or more direct or indirect (42 CFR, Section 455.102) interest in the ownership of this facility if applying for skilled nursing or intermediate care licensure, and 10 percent for all other facilities, agencies, or clinics. Provide federal employer's tax ID number. Are any of these persons (listed below) related to one another as spouse, parent, child or sibling? Submit an attachment for additional names that includes all of the required information listed below. Are they related to one another as Relationship Name of individual % Owned EIN Number a spouse, parent, child or sibling? (1) Yes No (2) Yes No (3) No Yes (4) Yes No (5) No Yes 8. Financial resources -- Only applies to SNF and ICF: Submit evidence, i.e., bank statements, line of credit, certificate(s) of deposit, satisfactory to the department(s) that the licensee possesses financial resources sufficient to operate the facility for a period of at least 45 days. (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.