Hs 215a 2025

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The document is a form (HS 215A) from the California Department of Public Health, Licensing and Certification, intended for individuals applying for a license to operate health or community care facilities. It collects personal information, criminal history, professional licenses, employment history, and involvement with other facilities. The form is mandatory for various stakeholders associated with the applicant facility and aims to ensure compliance with licensing requirements.

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Click ‘Get Form’ to open the HS 215A in the editor.
Begin by filling out the 'Identifying Information' section. Enter your full legal name, date of birth, and business address including city, state, and zip code.
In the 'Criminal Record' section, indicate whether you have any convictions. If yes, provide details as required.
Complete the 'Professional Licenses/Certificates' section by listing any relevant licenses held, along with their issuing agency and period held.
For the 'Employment/Business Summary', detail your last ten years of employment history starting with your most recent job. Include employer names and addresses.
Answer questions in the 'Facility, Agency, Clinic Involvement' section truthfully. If applicable, complete the attached Facility Information Sheet.
Finally, review all entries for accuracy before signing and dating the form at the bottom.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the phone number for CDPH licensing and certification?

For questions regarding the status of your facility license application, please contact the Centralized Applications Branch at (916) 552-8632 or email CAB@cdph.ca.gov.

What is the HS215A form?

The HS 215A form is required as part of a health care facility, agency, or clinics application. packet for state licensing and/or federal certification, including when changes are reported. regarding officers, directors, purchase of stock, etc., even though no change in legal. ownership has or is occurring.