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:

2. Has there been a judgment against you for Medicare or Medicaid (Medi-Cal) fraud or by a health care	Yes	No
professional/technical licensing entity?

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

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

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	Are any of the above Business Entities a “PARENT” organization to the	Trustee
SNF		OTHER Nature of Involvement (explain):
OTHER FACILITY TYPE (explain):	applicant facility? If Yes, explain.
	Yes	Dates of involvement:
	No	From:
		To:

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.

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.


Dates (From/To)		Dates that you were employed in position from the start to the end date.
Name and Address of Employer(s)		Name and street, city, state address of the employer.
Job Title		Title that you held within your company/place of employment.

E. FACILITY, AGENCY, CLINIC INVOLVEMENT (IN OR OUT OF CALIFORNIA)
Questions No. 1-3		Please 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 Form – Fill Out and Use This PDF

Hs 215A Form PDF Details