California Code of Regulations › Title 22 - Social Security › Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies › Chapter 8 - Intermediate Care Facilities for the Developmentally Disabled › Article 2 - License › Section 76205 - 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 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.