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HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Adult Day Health Center 

Report of Change Application Checklist for Change of Location

The following is a list of forms and supporting documents required for a complete application packet. Failure to include every form or document will delay processing or lead to denial.

Checklist and Instructions - P​lease submit your documents in this order and save a copy of all submitted documents for your records. 

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 address

  • Facility ID number (if known)

  • Brief description of request

  • Previous and proposed/new location

  • Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address)

    • The Department will use the invoice contact email address to invoice the application fee

    • The Department will use the applicant contact email address to send all application correspondence

  • General Contact Information (name, title, phone number, fax, email address, and alternative contact information)

    • The Department will use this information to contact the facility for day-to-day business

  • Emergency Contact Information (name, phone number, fax, email address, alternate email, 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)

  • All Facility Letter Contact Information (name, phone number, fax, and email address)

    • The Department will use this information to send All Facility Letters

  • Facility Contact (Public Use) Information (phone number, fax, email address, and website address)

    • The Department will use this information to store facility contact information for the public

  • Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)

    • The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents​

  • ​Signature​
​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 ​200 (PDF, 1.5MB)

Licensure & Certification Application 

[Health and Safety Code (HSC) section 1570.7 and 1575.2]

[Title 22 California Code of Regulations (CCR) section 78205(a)(8)]

Tips

  • Page 3, Section A, item 9 - List program hours and service hours

  • Page 6, section B, Item 6 —This parent company will have its own Federal tax ID number

  • Signature must be from the applicant (Licensee/owner), not the Administrator, unless the owner is the Administrator.

​Supporting Documents

​A.10 - Construction

[HSC section 1575.2]

[22 CCR section 78501(a)(1) and (b)] 

Submit one of the following:

  • 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).​

​Supporting Documents

​D.1 - Control of Property

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

HS 6​02​ (PDF)

Transfer Agreement

[22 CCR section 78205 (a)(12)]

Copy of current written transfer agreement with a hospital that meets the requirements of the California Code of Regulations.

  • May submit a CDPH 5000 Program Flex if Transfer Agreement cannot be obtained.

Tips 

  • The facility administrator may sign this form

  • The facility may not have a provider number yet and this line may be left blank​

CDA A​DH 0006 (PDF)​

Staffing/Services Arrangement ​

[22 CCR section 78205(a)(11)] 

Submit a copy of the ADH 0006.​

​CDA A​DH 0007 (PDF)

Proposal to Share Space

[HSC section 1578 and 1578.1]

If your facility will share space according to HSC section 1578 and 157.1, submit a copy of the ADH 0007 and a floor plan that indentifies the shared space(s). 

STD ​850​​ (PDF)​​

Fire Safety Inspection Request (not applicable for a CHOW unless there is construction)

[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 OSHPD 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 plant accommodations, general building requirements and space requirements 

    • Submit a detailed and legible floor plan of the “existing” or “proposed” ADHC indicating square footage of each of the areas to be used and noting where basic services will be provided so it can be determined if these requirements have been met. The floor plan should indicate:

      1. Office space

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

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

​Note: Save a copy of all submitted documents for your records. 
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