Cal. Code Regs. Tit. 22, § 76205 - 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 and signature of applicant and, if an individual, verification that the applicant has attained the age of 18 years. The application of a corporation or association shall be signed by a duly authorized representative. The application of a partnership shall be signed by each general partner.

(2) If an applicant is a corporation, a current copy of the corporate by-laws and articles of incorporation. If the applicant is a partnership, a copy of the partnership agreements.

(3) Type of facility to be operated and types of services for which approval is requested.

(4) The location of the facility and the basis upon which the applicant exercises control and possession thereof.

(5) Name and license number of the administrator in charge of the facility.

(6) 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 76205(a)(6) 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 a skilled nursing facility or 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 76205(a)(6) shall not apply to a bank, trust company, financial institution, title insurer, controlled escrow company or underwritten title company to which a license is issued in a fiduciary capacity.

(7) The name, title, principal business address and the percentage of ownership interest of all officers, directors, stockholders owning five percent or more of the stock, members, partners and all other persons having authority or responsibility for the operation of the facility and shall provide satisfactory evidence that all such persons are of reputable and responsible character.

(8) If the applicant is a political subdivision of the State or other governmental 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.

(9) The applicant shall demonstrate sufficient financial responsibility as may be necessary to operate the facility.

(10) A copy of the current organizational chart for the operation of the facility and a chart of the decision-making structure of the applicant entity.

(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.

(12) 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 skilled nursing facility for which application for license is made are of reputable and responsible character.

(13) Certificate of Need or a Certificate of Exemption from the Department if required by Chapter 1, Division 7, of this title.

Notes

Cal. Code Regs. Tit. 22, § 76205

Note: Authority cited: Section 208(a), Health and Safety Code. Reference: Sections 1265, 1267.5(c), (d), (e), (f), and 1276, Health and Safety Code.