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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 Bed (Capacity)

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 Bed (Capacity)

Forms and Supporting Documents​

​​Additional Instructions

(​​​Each form liste​d also has instructions on the form)​

​Cover Lette​​r

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
  • Contact 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 (https://ww​
  • 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
​Pre-Screened Approval 

​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 200 (PDF)

Licensure & Certification Application

[Health and Safety Code (HSC) section 1575.1 and 1575.2] [Title 22 California Code of Regulations (CCR) section 78205]


  • Page 6, section B, item 6 — An organization will have its own Federal tax ID number
Supporting Documents 

A.10 - Construction

[22 CCR section 78501(a)(1) and (b), 78227(1)]

If construction occurred or if a newly constructed building:

  • Submit evidence of compliance with local building code requirements or;
  • Certificate of Occupancy issued by the local building authority 

Note: ADHCs are not subject to architectural plan review by the Department of Health Care Access and Information (HCAI).

CDPH 609​ (PDF)

Bed or Service Request

[22 CCR section 78221]​

Top of page:

  • Under the “Existing Beds” category:
    • Include the bed count next to the applicable bed type
  • Under the “Requested Beds” category:
    • Include the new total bed count(s)
    • The “Approved Capacity” field should be left blank
  • Approved Capacity – Do not complete this section - For CAB use only
  • To remove a service from your license, in the “Requested Services” column, make sure the service you want removed is unchecked​
STD 850 (PDF)

Fire Safety Inspection Request

[HSC section 1574.7(b)] [22 CCR section 78409]​

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.

​Map and Floor Plans

Map and Floor Plans

[22 CCR sections 78205(a)(8), 78501, 78503, and 78505]

  • Submit a map identifying the ADHC service area
  • The physical plan accommodations, general building requirements and space requirements
    • Submit a detailed and legible floor plan of the “existing” or “proposed”​ changes indicating square footage and basic services. The floor plan should indicate:​
      1. ​Office Space

      2. Bathrooms (e.g., number of toilets and urinals in each bathroom)

      3. Entrances, emergency exits, and outdoor areas​​

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