Cal. Code Regs. Tit. 22, § 73205 - Content of Application
(a)
Any person, firm, partnership, association, corporation, political subdivision
of the State or other governmental agency, desiring to obtain a license shall
file with the Department an application on forms furnished by the Department.
The application shall contain the following:
(1) Name of applicant and, if an individual,
verification that the applicant has attained the age of 18 years.
(2) Type of facility to be operated and types
of services for which approval is requested.
(3) The location of the intermediate care
facility.
(4) Name and license
number of the administrator in charge of the intermediate care
facility.
(5) If the applicant is
an individual, satisfactory evidence that the applicant and the person in
charge of the intermediate care facility for which application for license is
made are of reputable and responsible character.
(6) If applicant is a firm, association,
organization, partnership, business trust, corporation or company, satisfactory
evidence that the members or shareholders holding five percent or more stock,
officers, any member having responsibility in the operation of the facility and
the person in charge of the intermediate care facility for which application
for license is made are of reputable and responsible character.
(7) If the applicant is a political
subdivision of the State or other government agency, satisfactory evidence that
the person in charge of the intermediate care facility, for which application
for license is made, is of reputable and responsible character.
(8) The name, title, principal business
address and the percentage of ownership interest of all officers, directors and
stockholders having a beneficial interest of 10 percent or more in the
applicant corporation or partnership. If any such person has served or
currently serves as an administrator, general partner, or corporate officer or
director of, or has held a beneficial ownership interest of 10 percent or more
in any other skilled nursing facility or intermediate care facility, or in any
community care facility licensed pursuant to Community Care Facility Act,
Chapter 3 (commencing with Section
1500) of the Health and Safety
Code, the applicant shall disclose to the Department the person's relationship
to the facility, including the name and current or last address of the health
facility or community care facility and the date such relationship commenced,
and if applicable, the date it was terminated. Each such person shall also
disclose whether he or she was an officer, director, general partner or owner
of a 10 percent or greater interest in a licensee of a skilled nursing
facility, intermediate care facility or community care facility at a time when
one or more violations of law were committed therein which resulted in
suspension or revocation of its license.
(A)
The provisions of Section
73205(a) (8)
shall not apply to the directors of a nonprofit corporation, which is exempt
from taxation under Section
23701(d)
of the Revenue and Taxation Code, and which operates an intermediate care
facility in conjunction with a licensed residential facility, where such
directors serve without financial compensation and are not compensated by the
nonprofit corporation in any other capacity. For purposes of this Section, a
person owning a 10 percent or greater beneficial interest in, or holding any
compensated position in any corporation, partnership, association, or trust
which is compensated by the nonprofit corporation in any capacity relating to
the facility shall be deemed to be compensated by the nonprofit
corporation.
(B) The provisions of
Section 73205(a) (8)
shall not apply to a bank, trust company, financial institutions, title
insurer, controlled escrow company or underwritten title company to which a
license is issued in a fiduciary capacity.
(9) Copy of the current organizational
chart.
(10) Certificate of Need or
a Certificate of Exemption from the Department if required by Chapter 1,
Division 7 of this title.
(11) Such
other information or documents (such as fingerprint cards and qualification
information forms) as may be required by the Department for the proper
administration and enforcement of the licensing statutes and
regulations.
Notes
2. Editorial correction of History Note 1 (Register 79, No. 5).
Note: Authority cited: Sections 208 and 1275, Health and Safety Code. Reference: Section 1267.5, Health and Safety Code.
2. Editorial correction of History Note 1 (Register 79, No. 5).
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