California Code of Regulations › Title 22 - Social Security › Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies › Chapter 4 - Intermediate Care Facilities › Article 2 - License › Section 73205 - Content of Application

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(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.