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HEALTH CARE FACILITY LICENSING AND CERTIFICATION

 Contact Us

Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

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 Program Director

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 Program Director

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
    • Include end date of prior person in the role and start date for current person in the role
  • 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.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

Tip

  • Search the Cal Health Find database for current staff - (https://www.cdph.ca.gov/Programs/CHCQ/LCP/CalHealthFind/pages/home.aspx)​
​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 215A (PDF)​

Applicant Individual Information 

[Health and Safety Code (HSC) section 1570.7]

[Title 22 California Code of Regulations (CCR) section 78205(2) and 78417]

This form must be completed and signed for the Program Director of the facility

Tips

  • Section A — List facility name and business address. Select facility type and type of application
  • Section B – List applicant`s legal name, nature of involvement to the facility, date of birth, driver`s license or state-issued identification number and expiration date, social security number
  • Section E — Submit ten years of employment history, indicating employer name and address, the start and end dates of employment, job title. The applicant may submit a resume in lieu of this section. The resume must contain all required information requested in section E
    • Be sure to include every facility where the applicant is a currently a program director
  • Section F — If answering yes to any question in this section, complete and attach the facility information sheet (section H)
  •   Applicant Release — Be sure that applicant signs and dates this section, print name and title

HS 215A Facility Information Sheet (PDF)

Facility Information Sheet

[HSC section 1575.1(a)(1)(2)] [22 CCR section 78205(a)(2)]

Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency:

  • Facility name
  • Facility address
  • Facility type
  • Individual's nature and dates of involvement
  • Entity name, type, and Employer Identification Number (EIN)
​​Supporting Documents

Resume

[22 CCR section 78205(a)(2)]

A resume is required for the Program Director

CDPH 325 (PDF)​
​Criminal Record Clearance Submissions

[HSC section 1575.7]​

  • Submit this form only for the new Program Director


Transmittal Application for Criminal Background Investigation

[HSC sections 1575.7(a)(1) and 1575.7(a)(2)]

Mail this form to the address indicated on the form only for the new Program Director

Submit this form to CDPH Criminal Background Section (address is listed on the form).

BCIA 8016​ (PDF)​


Request for Live Scan

[HSC section 1575.7]

Mail this form to the address indicated on the form only for the new Program Director


Note: In addition, submit copy of this form to CDPH Criminal Background Section. Centralized Applications Branch may also request a copy of this form.

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