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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 requires personal information, criminal record disclosure, professional licenses, employment history, and details about involvement with other facilities. The form aims to assess the applicant's qualifications and compliance with legal requirements for licensure.

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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.

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