āForms and Supporting Documentsā
| āāAdditional Instructions
(āāāEach form listeād also has instructions on the form)ā
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āCover Letteāār
| Cover Letterāā
Letter on company letterhead with the following information:ā
- 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://wwāw.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
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āPre-Screened Approval
Letter
| āPre-Screened Approval Letterā - 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
- āāNot required for Program of All-inclusive Care for the Elderly (PACE) Organizations
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āHS 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]
Tip - Page 6, section B, item 6 ā An organization will have its own Federal tax ID number
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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).
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āCDPH 609ā (PDF)
| Bed or Service Request [22 CCR section 78221]ā
Top of page: - Under the āExisting Bedsā category:
- Include the bed count next to the applicable bed type
- Under the āRequested Bedsā category:
- Include the new total bed count(s)
- The āApproved Capacityā field should be left blank
Tips - Approved Capacity ā Do not complete this section - For CAB use only
- To remove a service from your license, in the āRequested Servicesā column, make sure the service you want removed is uncheckedā
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āSTD 850 (PDF)
| āFire Safety Inspection Request [HSC section 1574.7(b)] [22 CCR section 78409]ā
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.
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āMap 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 āexistingā or āproposedāā changes indicating square footage and basic services. The floor plan should indicate:ā
āOffice Space Bathrooms (e.g., number of toilets and urinals in each bathroom) Entrances, emergency exits, and outdoor areasāā
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