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Phone: (916) 552-8632

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​​

Adult Day Health Center 

Report of Change Application Checklist for Change of Administrator

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 Administrator 

Forms an​d Supporting​ Docume​​nts​​

​​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 address
  • Facility ID number (if known)
  • Brief description of request
    • Include end date of prior person in the role and start date for the current person in the role
  • ​Cont​act information (name, title, phone number, and e-mail 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​ (
  • 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
  • ​Search the Cal Health Find database for current staff (
​Pre-Screened Approval Letter
Pre-Screened Approval Letter
  • Required for Community-Based Adult Services (CBAS) Programs Only
  • This letter is issued by the California Department of Aging and only required for CBAS participants
  • Not required for Program of All-inclusive Care for the Elderly (PACE) Organizations

HS 215A (PDF)​

Applicant Individual Information 

[Title 22 California Code of Regulations (CCR) section 78205(a)(2) and 78415(a)]​

  • This form must be completed and signed for the administrator of the facility
  • Section A — List facility name and business address. Select facility type and type of application
  • Section B – List applicant’s legal name, nature of involvement to the facility, date of birth, driver’s license or state-issued identification number and expiration date, social security number
  • Section E — Submit ten years of employment history, indicating employer name and address, the start and end dates of employment, job title. The applicant may submit a resume in lieu of this section. The resume must contain all required information requested in section E
    • Be sure to include every facility where the applicant is a currently an administrator
  • Section F — If answering yes to any question in this section, complete and attach the facility information sheet (section H)
  • Applicant Release — Be sure that applicant signs and dates this section, print name and title

HS 215A – Facility Information Sheet​ (PDF)

Section H – Facility Information Sheet

[22 CCR 78205(a)(2) and 78415]

Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency:

  • Facility name
  • Facility address
  • Facility type
  • Individual’s nature and dates of involvement

Entity name, type, and Employer Identification Number (EIN)​

Supporting Documents​


[22 CCR section 78205(a)(2) and 78415] 

A resume is required for the administrator

CDPH 5000 (PDF)

Program Flexibility Request

[22 CCR sections 78217 and 78415(g)]​

Submit request if administrator will be responsible for more than three (3) centers

CDPH 325 (PDF)​

​Criminal Record Clearance Submissions

[Health and Safety Code (HSC) section 1575.7]​

  • Submit for the administrator
CDPH 322​​ (PDF)​

​Transmittal Application for Criminal Background Investigation 

[HSC section 1575.7]

Mail this form to the address indicated on the form only for the new administrator​

Submit this form to CDPH Criminal Background Section (address is listed on the form).

BCIA 8016​ (PDF)​

Request for Live Scan

[HSC section 1575.7]

Mail this form to the address indicated on the form only for the new administrator​

Note: In addition, submit copy of this form to CDPH Criminal Background Section. Centralized Applications Branch may also request a copy of this form.

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