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)​
  

[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

Resume

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

A resume is required for the 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).