Cal. Code Regs. Tit. 22, § 74661 - Application for License
(a)
Any person, firm, partnership, association, corporation, receiver, political
subdivision of the State or other governmental agency desiring to obtain a
license shall file with the Department an application. Applicants shall use the
Department's forms: Application for Facility License HS 200 (March, 1996),
Disclosure of Ownership HS 215 (March, 1996), and Administrative
Organization/Organizational Structure HS 309 (September, 1995). These forms and
instructions are herein incorporated by reference. The application shall
contain the following:
(1) Name and address
of applicant.
(A) If an individual,
verification that the applicant has attained the age of 18 years.
(B) For all incorporated applicants, the date
and state of incorporation, corporation number and, if a foreign corporation,
evidence of authority to do business in the State of
California.
(2) The type
of services for which approval is requested.
(3) The location of the home health agency
and branch offices and basis upon which the applicant exercises control and
possession thereof.
(4) The name of
the administrator in charge of the home health agency.
(5) The name and principal business address
and the percentage of ownership interest of all officers, directors,
stockholders owning 5 percent or more of stock, members, partners and all other
persons having authority or responsibility for the operation of the agency and
shall provide evidence that all such persons are of reputable and responsible
character.
(6) Proof of sufficient
financial responsibility as may be necessary to operate the agency.
(7) A copy of the current organizational
chart.
Notes
Note: Authority cited: Sections 1734 and 100275, Health and Safety Code. Reference: Sections 1728.1 and 1734, Health and Safety Code.
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