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The submission notifies the California Department of Public Health Licensing and Certification of a change of ownership, identifies the responsible individual and officer role, and provides facility and licensee identifiers, addresses, and emergency contact information. The form collects application type, ownership certification effective date, change type selections, facility type classification, Medicare/Medi-Cal interest, bed capacity, operational details, and licensee ownership/management documentation requirements.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/refrlag-chst-sample-application/396244/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/refrlag-chst-sample-application/396244.png","ImageObject",300,407,{"name":92,"@type":93},"ahduag","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-29","2026-09-26",true,{"@type":102,"interactionType":103,"userInteractionCount":34},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What ownership change is being submitted and for what certification purpose?","Question",{"text":112,"@type":113},"The cover letter states that a change of stock transfer is being submitted, with the effective date for certification tied to when the financial management responsibility was taken, rather than the sale date or state license change date.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"Which agencies and facility details are included in the submission?",{"text":117,"@type":113},"The materials include the facility name and address, facility ID number, licensee name and license number, and direct mailing attention to the California Department of Public Health Licensing and Certification.",{"name":119,"@type":110,"acceptedAnswer":120},"What information does the application request about the change and facility type?",{"text":121,"@type":113},"The form collects the application type, the type of change selections (including stock transfer), facility type classification options, bed capacity (current and proposed), operating days/hours, whether construction is required, and interest in Medicare and Medi-Cal programs.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},396244,1790694057,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":34,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":139,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":145,"preview_page_count":4},3985747870414,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Cover Letter  \nABC Healthcare Services, Inc.  \n999 Beach Side Court, Sacramento, CA 95814  \nP: (999) 555-2626  \nF: (999) 555-2600 [Email:](Email: ABChealthcareservices@gmail.com)[ ](Email: ABChealthcareservices@gmail.com)[ABChealthcareservices@gmail.com](Email: ABChealthcareservices@gmail.com)  \nMarch 15, 2019  \nVIA PRIORITY MAIL:  \nCalifornia Department of Public Health Licensing and Certification  \nP. O. Box 997377, MS 3207 Sacramento, CA 95899  \nAttn: Centralized Applications Branch  \nTo Whom It May Concern ,  \nWe are submitting this Change of Stock Transfer application. Harry Stone purchased 49% of the stock and he is the Secretary and Chief Financial Officer for the licensee.  \nFacility Name: ABC Healthcare Referral Agency  \nFacility Address: 1800 Beach Drive, Sacramento, CA 95814  \nFacility ID Number: 080000000  \nLicensee Name: ABC Healthcare Services, Inc.  \nLicense Number: 123456789  \nI enclosed the required application forms and supporting documents needed to process this change.  \nShould you have any questions, I will be the direct contact regarding this change.  \nEmergency Contact Information (available 365/24/7)  \nName: Jane Doe  \n[Email:](Email: ABChealthcareservices@gmail.com)[ ](Email: ABChealthcareservices@gmail.com)[ABChealthcareservices@gmail.com](Email: ABChealthcareservices@gmail.com)  \nAlternate Email: [JaneDoe@cmail.com](JaneDoe@cmail.com)  \n[Phone:](Phone:) (999) 555-2626  \nPhone (Text Messages): (999) 555-5555  \nFax: (999) 555-2600  \nSincerely,  \nJane Doe, Owner  \nABC Healthcare Services, Inc.  \nHS 200  \nCalifornia Department of Public Health Licensing and Certification  \nLICENSURE & CERTIFICATION APPLICATION  \n\n| FOR DEPARTMENTAL USE ONLY |  |\n| --- | --- |\n|  |  |\n| Proposed name of facility/agency/clinic: |  |\n|  |  |\n\nA. APPLICATION INFORMATION  \n1. Type of application (check one):  \n a. Initial  c. Management company (see Sections C1-5, F, and Attachment E-1)  \n b. Change of Ownership (see \\#2 below) d. Other change (see Section A4):    \n2. Change of Ownership Only -For Certification Purposes:  \nWe wish to make certain that our records correctly show the effective date of the ownership change for certification. This date should reflect the actual date on which you took charge of the financial management of the facility rather than the date of sale or date of state license change. Effective date of change:    \n3. Amount of fee enclosed: $   \n4. Type of Change (check all that apply):  \n a. Not applicable  f. Change of bed classification    \n b. Change of capacity (see \\# 8 below)  g. Change of name  \n c. Change of location  h. Construction of new or replacement facility  \nd. Change of services  i. Stock transfer   e. Change of facility type j. Other (specify)     \n5. Type of facility, agency, or clinic (check one)  \n a. Skilled Nursing Facility (SNF)  i.   \n b. Intermediate Care Facility (ICF)  j. General acute care hospital  \n c. ICF/Developmentally Disabled (ICF/DD)  k. Adult day health care center  \n d. ICF/DD-Habilitative (ICF/DD-H)  l. Home Health Agency (HHA)  \n e. ICF/DD-Nursing (ICF/DD-N)  m. Hospice  \n f.  ~~ ~~   n. Chronic dialysis clinic  \n g.  ~~ ~~   o. Other (specify)   \n h. Surgical clinic  \n6. a. Do you wish to apply for the Medicare program?  Yes  No Medicare Provider \\#:    \nb. Fiscal Intermediary choice:    \n| 7. Do you wish to apply for the Medi-Cal (Medicaid) program? |  Yes  No |\n| --- | --- |\n\n8. a. Current facility bed capacity:  \nb. Proposed facility bed capacity:  \n9. Age range of clients:    \n10. Days and hours of operation:  ~~ ~~  ~~ ~~     \n11. Is construction required? Yes  No  \nIf \"yes\", date construction to begin:  \nIf \"yes\", date construction to be completed:     \nHS 200 (02/08) 1  \nB. LICENSEE INFORMATION  \n1. Licensee name:    \n3. Owner type (check one):~~ ~~Submit organizational chart for b, c, d, and e.  \n a. Sole proprietorship (Individual)  g. City  \n b. Profit corporation  h. County  \n c. Nonprofit corporation  i. State agency  \n d. Limited Liability Company ","cbCaiq6PjWsWYBuZ","https://ap.wps.com/l/cbCaiq6PjWsWYBuZ","pdf",2758923,26,"English","# Cover letter and submission overview\n## Ownership change and contact information\n# Licensure & certification application form\n## A. Application information\n## B. Licensee information","[{\"question\":\"What ownership change is being submitted and for what certification purpose?\",\"answer\":\"The cover letter states that a change of stock transfer is being submitted, with the effective date for certification tied to when the financial management responsibility was taken, rather than the sale date or state license change date.\"},{\"question\":\"Which agencies and facility details are included in the submission?\",\"answer\":\"The materials include the facility name and address, facility ID number, licensee name and license number, and direct mailing attention to the California Department of Public Health Licensing and Certification.\"},{\"question\":\"What information does the application request about the change and facility type?\",\"answer\":\"The form collects the application type, the type of change selections (including stock transfer), facility type classification options, bed capacity (current and proposed), operating days/hours, whether construction is required, and interest in Medicare and Medi-Cal programs.\"}]","REFRLAG CHST Sample Application | PDF",1790437792,66]