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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 Service (Hours/Days of Operations and Adding Adult Day Program)

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 Service, Change of Hours/Days of Operations and Adding Adult Day Program​

Forms and Supporting Documents​

​​Additional Instructions

(​​​Each fo​​rm 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
  • 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://www.calhospitalprepare.o​rg/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 15752 and 1575.1] [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 78227(1) and 78501(a)(1) and (b)]

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).​

CDA ADH 0006 (PDF)​

Staffing/Services Arrangement ​

[22 CCR section 78205(a)(11)] 

Submit a copy of the ADH 0006.​

CDA ADH 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.

​​​CDPH 609​ (PDF) 
Bed or Service Request (only if applying to add Adult Day Program or CBAS providers adding Emergency Remote Services)

[HSC section 1578.1(b)]

[22 CCR section 78221 and 78347]

Bottom page:

  • Under the “Existing Services” category:
    • Place a checkmark next to the applicable service types
  • Under the “Requested Services” category:
    • Place a checkmark next to all applicable service types, adding a checkmark to an additional service or omitting a checkmark next to the service you are requesting to remove
  • Approved Capacity – Do not complete this section - For Centralized Applications Branch 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 OSHPD Fire Life & Safety (FLS) Inspection approval does not replace this form

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