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Question	Answer
Form Name	Hs 215A Form
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	hs 215, hs form, hs215a, ics form 215a

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State of California – Health and Human Services Agency	California Department of Public Health
	Licensing and Certification

	FOR DEPARTMENTAL USE ONLY

District:		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

Date of Birth

City, State, & Zip

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.

B.Criminal Record

1.Have you ever been convicted of an offense that is still on your record, whether misdemeanor or felony? Yes No

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

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

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

Job title

From:

To:

From:

To:

From:

To:

From:

To:

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?

Yes

If YES, complete Section F (below) and the “Facility Information Sheet” (attached).

2.Have you ever operated or managed (including management agreements) any of the following facility types?

Yes	No	If YES, complete Section F (below) and the “Facility Information Sheet” (attached).

		Adult Day Health Care Center	ICF/DD

		Clinics	ICF/DD-H
		COMMUNITY CARE FACILITY	ICF-DD-N

		General Acute Care Hospital	Intermediate Care Facility

		Health Facility	Pediatric Day Health & Respite Care

		Home Health Agency	Residential Care Facility for the Elderly
		Hospice	Skilled Nursing Facility

			Other

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

following adverse actions?	Yes	No	If YES, check all applicable:
Had a final Medi-Cal decertification action taken				Placed on probation	Receiver appointed
Resolved by settlement	Revocation action filed			Revoked (whether stayed or not)	Suspension

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)

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:

Facility address (number, street, city):

State:

Zip code:

Type of Facility	“Type” of Business Entity	Individual’s “Nature” of Involvement
Adult Day Health Care Center	For EACH business entity, identify the name & EIN of the entity:	Administrator of Clinic, SNF or ICF
Clinic	Corporation:	Agent
COMMUNITY CARE FACILITY		Director
General Acute Care Hospital	Individual:	Licensee
Health Facility		Manager of “parent” organization
HHA	LLC:	Managing employee of a HHA
Hospice		Member
ICF	Management Company:	Officer of corporation
ICF/DD		Owner
ICF/DD-H	Partnership:	Partner
ICF/DD-N		Sole Proprietorship
ICF	OTHER Business Entity (explain):	Stockholder -- Ownership %:
Residential Care for the Elderly		Trustee
SNF	Are any of the above Business Entities a “PARENT” organization to the	OTHER Nature of Involvement (explain):
OTHER FACILITY TYPE (explain):	applicant facility? If Yes, explain.
OTHER FACILITY TYPE (explain):
	Yes	Dates of involvement:
	No	From:
		To:

Facility name:

Facility address (number, street, city):

State:

Zip code:

Type of Facility	“Type” of Business Entity	Individual’s “Nature” of Involvement
Adult Day Health Care Center	For EACH business entity, identify the name & EIN of the entity:	Administrator of Clinic, SNF or ICF
Clinic	Corporation:	Agent
COMMUNITY CARE FACILITY		Director
General Acute Care Hospital	Individual:	Licensee
Health Facility		Manager of “parent” organization
HHA	LLC:	Managing employee of a HHA
Hospice		Member
ICF	Management Company:	Officer of corporation
ICF/DD		Owner
ICF/DD-H	Partnership:	Partner
ICF/DD-N		Sole Proprietorship
ICF	OTHER Business Entity (explain):	Stockholder -- Ownership %:
Residential Care for the Elderly		Trustee
SNF	Are any of the above Business Entities a “PARENT” organization to the	OTHER Nature of Involvement (explain):
OTHER FACILITY TYPE (explain):	applicant facility? If Yes, explain.
OTHER FACILITY TYPE (explain):
	Yes	Dates of involvement:
	No	Dates of involvement:
	No	From:
		From:
		To:

Facility name:

Facility address (number, street, city):

State:

Zip code:

Type of Facility	“Type” of Business Entity	Individual’s “Nature” of Involvement
Adult Day Health Care Center	For EACH business entity, identify the name & EIN of the entity:	Administrator of Clinic, SNF or ICF
Clinic	Corporation:	Agent
COMMUNITY CARE FACILITY		Director
General Acute Care Hospital	Individual:	Licensee
Health Facility		Manager of “parent” organization
HHA	LLC:	Managing employee of a HHA
Hospice		Member
ICF	Management Company:	Officer of corporation
ICF/DD		Owner
ICF/DD-H	Partnership:	Partner
ICF/DD-N		Sole Proprietorship
ICF	OTHER Business Entity (explain):	Stockholder -- Ownership %:
Residential Care for the Elderly		Trustee
SNF	Are any of the above Business Entities a “PARENT” organization to the	OTHER Nature of Involvement (explain):
OTHER FACILITY TYPE (explain):	applicant facility? If Yes, explain.
OTHER FACILITY TYPE (explain):
	Yes	Dates of involvement:
	No	Dates of involvement:
	No	From:
		From:
		To:

HS 215A (2/08)

State of California – Health and Human Services Agency	California Department of Public Health
	Licensing and Certification

Facility name:

Facility address (number, street, city):

State:

Zip code:

Type of Facility	“Type” of Business Entity	Individual’s “Nature” of Involvement
Adult Day Health Care Center	For EACH business entity, identify the name & EIN of the entity:	Administrator of Clinic, SNF or ICF
Clinic	Corporation:	Agent
COMMUNITY CARE FACILITY		Director
General Acute Care Hospital	Individual:	Licensee
Health Facility		Manager of “parent” organization
HHA	LLC:	Managing employee of a HHA
Hospice		Member
ICF	Management Company:	Officer of corporation
ICF/DD		Owner
ICF/DD-H	Partnership:	Partner
ICF/DD-N		Sole Proprietorship
ICF	OTHER Business Entity (explain):	Stockholder -- Ownership %:
Residential Care for the Elderly		Trustee
SNF	Are any of the above Business Entities a “PARENT” organization to the	OTHER Nature of Involvement (explain):
OTHER FACILITY TYPE (explain):	applicant facility? If Yes, explain.
OTHER FACILITY TYPE (explain):
	Yes	Dates of involvement:
	No	Dates of involvement:
	No	From:
		From:
		To:

Facility name:

Facility address (number, street, city):

State:

Zip code:

Type of Facility	“Type” of Business Entity	Individual’s “Nature” of Involvement
Adult Day Health Care Center	For EACH business entity, identify the name & EIN of the entity:	Administrator of Clinic, SNF or ICF
Clinic	Corporation:	Agent
COMMUNITY CARE FACILITY		Director
General Acute Care Hospital	Individual:	Licensee
Health Facility		Manager of “parent” organization
HHA	LLC:	Managing employee of a HHA
Hospice		Member
ICF	Management Company:	Officer of corporation
ICF/DD		Owner
ICF/DD-H	Partnership:	Partner
ICF/DD-N		Sole Proprietorship
ICF	OTHER Business Entity (explain):	Stockholder -- Ownership %:
Residential Care for the Elderly		Trustee
SNF	Are any of the above Business Entities a “PARENT” organization to the	OTHER Nature of Involvement (explain):
OTHER FACILITY TYPE (explain):	applicant facility? If Yes, explain.
OTHER FACILITY TYPE (explain):
	Yes	Dates of involvement:
	No	Dates of involvement:
	No	From:
		From:
		To:

Facility name:

Facility address (number, street, city):

State:

Zip code:

Type of Facility	“Type” of Business Entity	Individual’s “Nature” of Involvement
Adult Day Health Care Center	For EACH business entity, identify the name & EIN of the entity:	Administrator of Clinic, SNF or ICF
Clinic	Corporation:	Agent
COMMUNITY CARE FACILITY		Director
General Acute Care Hospital	Individual:	Licensee
Health Facility		Manager of “parent” organization
HHA	LLC:	Managing employee of a HHA
Hospice		Member
ICF	Management Company:	Officer of corporation
ICF/DD		Owner
ICF/DD-H	Partnership:	Partner
ICF/DD-N		Sole Proprietorship
ICF	OTHER Business Entity (explain):	Stockholder -- Ownership %:
Residential Care for the Elderly		Trustee
SNF	Are any of the above Business Entities a “PARENT” organization to the	OTHER Nature of Involvement (explain):
OTHER FACILITY TYPE (explain):	applicant facility? If Yes, explain.
OTHER FACILITY TYPE (explain):
	Yes	Dates of involvement:
	No	Dates of involvement:
	No	From:
		From:
		To:

HS 215A (2/08)	4

Dates that you were employed in position from the start to the end date.

Name and street, city, state address of the employer.

Title that you held within your company/place of employment.

State of California – Health and Human Services Agency	California Department of Public Health
	Licensing and Certification

INSTRUCTIONS FOR HS 215A

The HS 215A must contain an original signature and date. The date of this form should be within the last three months.

This form is intended for the following:

1.Any individual owning an applicant facility;

2.Each agent, each partner, each director, each member, each managing employee of a HHA, each officer of a corporation;

3.Each agent, each partner, each director, each officer, each member or manager of a parent organization of licensee applicant;

4.Each manager, each member of a limited liability company;

5.Administrators;

6.Each person having a beneficial interest of 5 percent or more in the applicant corporation, applicant limited liability company, applicant partnership, applicant management company, applicant facility or private agency; and

7.Each officer and each director of the parent of the management company.

District office and ELMS Number	To be completed by the California Department of Public Health

Proposed name of facility/agency/clinic	Enter the name of your facility as it appears on your application (HS 200).
A. IDENTIFYING INFORMATION
Name	Please enter your full legal name.

Date of birth	Day/Month/Year

Business Address	Location of your business; number, street, apartment/suite number or letter if applicable.

City	City where business is located.

State	State where business is located.

Zip code	Zip code where business is located

Title in relation to this facility	Your title in relation to this facility.

If an Administrator for proposed clinic, list hours	Please list hours spent at each clinic per week. If your title is not administrator, please list N/A.
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.
Have you applied for any license for a health	Please answer yes or no. If yes, list any other names you have used if you have ever applied for a
facility or community care facility regardless of	health facility or community care facility license.
your role or title using any name other than your
true full name? If yes, list all other names.

B. CRIMINAL RECORD

Please check appropriate box. If you have checked ‘yes’, please provide dates and conviction information. If not applicable, please enter ‘N/A’.

C. PROFESSIONAL LICENSES/CERTIFICATES

Type	Type of licenses or certificate that you hold.

Period held	Dates that you held your license.

Issuing Agency	Agency that issued you a license and/or certificate.

D.EMPLOYMENT/BUSINESS SUMMARY (FOR LAST10 YEARS). Please list any additional experience that qualifies you to operate this type of facility. If self employed, never worked or now retired, indicate the ‘From’ and ‘To’ dates. Begin with your most recent job. Attach additional pages if necessary.

Dates (From/To)

Name and Address of Employer(s)

Job Title

E. FACILITY, AGENCY, CLINIC INVOLVEMENT (IN OR OUT OF CALIFORNIA)

Questions No. 1-3Please check appropriate box(es). If you have checked yes, you must fill out the attached “Facility

Information Sheet” and complete Section F.

F. ADVERSE ACTIONS

Please check appropriate box. If box is checked yes, please explain and include facility information.

FACILITY INFORMATION SHEET

Facility Name	Name of Facility that correlates to the checkboxes you have checked as ‘yes’ in Section E.

Facility address	Number and street address of the facility involved.

City	City where facility is located.
State	State where facility is located.
ZIP code	Zip code where facility is located.

Type of Facility	Check appropriate health facility.

“Type” of Business Entity	Check appropriate business entity and identify if this entity is a “parent” corporation to the applicant
	facility.
Individual “Nature” of Involvement	Check appropriate position held at that facility.

HS 215A (2/08)

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