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HEALTH CARE FACILITY LICENSING AND CERTIFICATION

 Contact Us

Phone: (916) 552-8632

Email: CAB@cdph.ca.gov

For application status requests, please include the following in your email:

  • Application ID (if applicable)
  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Number​​​​​

Alternative Birth Center

Report of Change Application Checklist for Change of Location

The following is a list of application forms and supporting documents required for a complete application packet. Failure to include each of the forms and documents will delay processing.

Checklist and Instructions - P​lease submit your documents in this order

Required Documents for a Change of Location

Forms and Supporting​​ Documents​​

​​Additional Instructions

(​​​Each form listed also has instructions on the form)​

​Cover Letter​

Cover Letter

Letter on company letterhead with the following information:

  • License number
  • Facility name and ID number (if known)
  • Brief description of request
  • Attestation that the applicant provider is located in proximity, in time and distance, to a facility with the capacity for management of obstetrical and neonatal emergencies, including the ability to provide cesarean section delivery, within 30 minutes from time of diagnosis of the emergency. Include the facility name and address with the capacity for management of obstetrical and neonatal emergencies [Health and Safety Code (HSC) section 1204.3(4)(A)]
  • Previous and proposed/new location
  • Contact information (name, title, phone number, and
    email address)
  • Emergency Contact Information (name, email, alternate email, phone, fax, and phone number that will receive text messages). The Department will use this information to contact the provider in the event of an emergency using the California Health Alert Network (CAHAN). All information provided must allow CAHAN to contact the provider on a 24/7/365 basis for distribution of health alerts. For additional information: CAHAN (https://www.calhospitalprepare.org/cahan)
  • Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address)​
  • Signature
HS 200 (PDF)

Licensure & Certification Application

[Health and Safety Code (HSC) section 1212]

Tip

  • Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions


A.10 – California Department of Health Care Access and Information (HCAI) and/or Certificate of Occupancy

[California Building Code (CBC) section 1226]

[HSC section 1226]​

For a newly licensed, constructed, or remodeled building, the following is required:

  • Title 24 compliance (OSHPD 3 Standards) - a California licensed architect or the local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements:
     
    • California Building Code (CBC)
    • California Fire Code (CFC)
    • California Electrical Code (CEC)
    • California Mechanical Code (CMC)
    • California Plumbing Code (CPC)
    • California Administrative Code (CAC)

* CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, is an acceptable form to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by a California licensed architect or local building authority. 

  • ​​​​​Certificate of Occupancy 
Supporting Documents ​

D.1 – Control of Property

[HSC section 1212]

Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the licensee

​STD 850​ (PDF)

Fire Safety Inspection Request
 
The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form

Medi-Cal Certification Documents 

​Forms and Supporting Documents
​Additional Instructions
(Each form listed also has instructions on the form)

​DHCS 9098​ (PDF)

Medi-Cal Provider Agreement

  • Do not leave any questions blank. Enter “same” or “N/A” if not applicable
  • The mailing address must be the same as reported on the HS 200 form, section C, Page 3, item  4
  • Notarized signature page is required
  • Submit the “Acknowledgement” page from the notary public


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