(a) A clinic corporation on behalf of a primary care clinic that has held a valid, unrevoked, and unsuspended license for at least the immediately preceding five years, with no demonstrated history of repeated or uncorrected violations of this chapter or a regulation adopted under this chapter that pose immediate jeopardy to a patient, as defined in subdivision (f), and that has no pending action to suspend or revoke its license, may file an affiliate clinic application under this section to establish a primary care clinic at an additional site or a mobile health care unit, either of which shall hereafter be referred to as the affiliate clinic. The department, upon receipt of the completed affiliate clinic application submitted by the clinic corporation, shall approve a license for the affiliate clinic, without the necessity of first conducting an initial onsite survey, if all of the following conditions are met:

1. (1) The clinic corporation that operates the existing licensed primary care clinic, which shall hereafter be referred to as the parent clinic, has submitted a completed affiliate clinic application and the associated application fee.
2. (2) The parent and affiliate clinics’ corporate officers, as specified in Section 5213 of the Corporations Code, are the same.
3. (3) The parent and affiliate clinics are owned and operated by the same nonprofit organization with the same board of directors.
4. (4) The parent and affiliate clinics have the same medical director or directors and medical policies, procedures, protocols, and standards.

(b) The affiliate clinic application shall consist solely of a simple form and required supporting documents giving the following information:

1. (1) The name and address of the clinic corporation’s administrative office.
2. (2) The name and contact information of the clinic corporation’s chief executive officer or executive director.
3. (3) The name and address of the new affiliate primary care clinic site or the location of the new affiliate mobile health care unit.
4. (4) The name and contact information of the administrator of the new affiliate primary care clinic site or mobile health care unit.
5. (5) The expected days and hours of operation and the services to be provided at the new affiliate primary care clinic site or mobile health care unit.
6. (6) Evidence that the new affiliate mobile health care unit meets the requirements of the Mobile Health Care Services Act (Chapter 9 (commencing with Section 1765.101)).
7. (7) The type and the manufacturer of the new affiliate mobile health care unit and the proposed area or areas where the new affiliate mobile health care unit will be providing services.
8. (8) To the extent otherwise required by law, evidence of compliance with the minimum construction standards for adequacy and safety of the new affiliate clinic’s physical plant, pursuant to the OSHPD 3 requirements of the most recent version of the California Building Code applicable to clinics and subdivision (b) of Section 1226. The compliance may be established in the form prescribed by Section 1226.3.
9. (9) Evidence of fire clearance for the new affiliate clinic site.
10. (10) A copy of the lease or purchase agreement for the new affiliate clinic site.
11. (11) A copy of the transfer agreement between the new affiliate clinic and a local hospital.
12. (12) A current list of clinic corporation board members.