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HEALTH CARE FACILITY LICENSING AND CERTIFICATION​

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

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

  • 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
​HS 2​00 (PDF, 1.5MB)

Licensure & Certification Application 

[Health and Safety Code (HSC) section 1570.7, 1575.2 and 1575.1]

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

Tip

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

  • Page 6, section B, item 6 — An organization 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

[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 0​006 (PDF)​

Staffing/Services Arrangement ​

[22 CCR section 78205(a)(11)] 

Submit a copy of the ADH 0006.​

Note: Not required for CBAS providers adding Emergency Remote Services.​​

​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 and a floor plan that identifies the shared space(s).
​​​CDP​H 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

Tips

  • 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 8​50​​ (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
​
Note: Save a copy of all submitted documents for your records. 
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