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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health



Application Request for a
Skilled Nursing Facility or Intermediate Care Facility

These instructions are to assist you in preparing a skilled nursing facility (SNF) or intermediate care facility (ICF) licensing and/or certification (for Medi-Cal Title 19 and/or Medicare Title 18 reimbursement) application package to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program. When preparing your application package, please use the following applicable checklist(s): 

Licensing Requirements

A state license is required to operate a SNF or ICF in California, which are defined as:

  • SNF means "a health facility that provides skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis," pursuant to Section 1250(c) of the Health and Safety (H&S) Code.
  • ICF means "a health facility that provides inpatient care to ambulatory or no ambulatory patients who have recurring need for skilled nursing supervision and need supportive care, but who do not require availability of continuous skilled nursing care," pursuant to Section 1250(d) of the H&S Code.

An application package is required for: (1) a new (initial) SNF or ICF facility; and
(2)whenever a CHOW occurs. A CHOW is the only "change" requiring a new application package to be submitted to L&C’s Centralized Applications Unit(CAB), pursuant to Title 22 of the California Code of Regulations (CCR) Section 72201. All other changes (besides a CHOW) must also be reported to the L&C CAB in writing within 10 days of the change, pursuant to Title 22 CCR Sections 72211 and 73225. These other changes do not require submittal of a new application package. The CAB will assist you on which forms on the checklist that must be submitted for the specific change to the license.


Completion of Applications

For your convenience, each checklist has instructions to complete the forms required for licensing and/or certification of SNF or ICF. The checklist provides specific item numbers that applicants typically have encountered problems in submitting incorrect or missing information. Please make sure that all item numbers in each form are completely filled out. For example: (1) the applicant’s formal name must be consistently the same throughout all the documents in the application package; or (2) in some instances, a specific attachment may need to be submitted with a specific form. All forms are required to be signed by the "licensee", owners or officers, unless otherwise stated.

Please read each required application package form carefully and provide all requested supplemental documents. Use the guidance below: 

  • Do not leave any items blank.
  • If a question does not apply, please respond with "Not Applicable" or "N.A."
  • Do not make changes to these forms.
  • Use "blue" ink to sign all forms.
  • Do not use white out/correction fluid to make corrections.
  • To correct an error, place a single line through the entry and enter the correct information. The individual responsible for making the correction must initial and date the correction.
  • There are some differences between documents required for a CHOW and "initial" applications that are noted on the checklist. 

You should retain a photocopy of the completed documents for your files. We may need to contact you in the future and we will be referring to the information in the documents you provided.


Submission of Applications

All completed application packages must be submitted via regular mail to:

California Department of Public Health
Licensing and Certification Program
Centralized Applications Branch
P.O. Box 997377, MS 3207
Sacramento, CA 95899-7377

CAB will review the application package for completion. Once the application package has been given a recommendation of "approved" by the CAB, and all required surveys have been performed, CAB will issue the license accordingly.

In addition, a check or money order made payable to the "California Department of Public Health" for the licensing fee, determined pursuant to H&S Code Section 1266, must accompany the required forms before your application will be processed. The licensing fees change annually; therefore, please check the current licensing fee for a SNF or ICF which is posted on the L&C Facility Fee website.

The application fee will not be returned if the application package is withdrawn or denied pursuant to Title 22 CCR Sections 72203(a)(2) and 73208(a)(2).

The application package review process will consider the applicant’s and associates’ (i.e., board members, LLC members, managers, etc.) past compliance history. This will be based on a review of all facilities and agencies operated by those individuals in California and nationally. The applicant and associates must demonstrate substantial compliance with state and federal requirements for all facilities that they operate.

Failure to demonstrate substantial compliance history may result in the denial of your application package. You will be notified in writing of L&C’s intent to deny the application.


National Provider Identifier

To apply for National Provider Identifier (NPI), go to the following National Plan and Provider Enumeration System website

 
Initial Licensing Survey

An initial licensing survey is part of the application process for "new" SNF or ICF applications. The initial licensing survey is a scheduled survey conducted by L&C district offices (DO) in the facility.

Except for the Los Angeles (LA) facilities, the DO will notify you (via letter), when the application has been approved by CAB and will schedule an "initial" licensing survey. For the LA facilities, the CAB will notify you (via letter) when the application has been approved and will schedule an "initial" licensing survey.

Note: You must be ready for the initial licensing survey upon notification. It is L&C’s policy that, except for very unusual circumstances, only one inspection visit will be made. Failure of the facility to be in substantial compliance, at the time of the visit, will result in the "denial" of the application package. Any further activity regarding your request, after such denial, will require a new application and license fee.

Please Note: An "initial" license will not be issued until the application is approved and, if required, a successful licensing survey is conducted.

Once you have had your initial licensing survey, you need to notify the L&C DO that you are ready and prepared to have an initial certification survey, if you received approval from CMS.

In addition, you must be in compliance with state licensing laws and federal conditions of participation


For CHOWs "Only"

Within 30 days of approval and issuance of a new license for a CHOW, the skilled nursing facility shall send written notification to all current residents and patients and to the primary contacts listed in the admission agreement of each resident and patient. The notice shall disclose the name of the owner and licensee of the facility and the name and contact information of a single entity that is responsible for all aspects of patient care and the operation of the facility.

The facility will also notify the DO with a copy of the written notice and a copy of the list of individuals and mailing addresses to whom the facility sent the notification as satisfactory evidence that the facility provided the required written notification.


If you have any questions, please contact the CAB, at (916) 552-8632 or by e-mail at CAB@cdph.ca.gov.

Attachment: Notice – Quality Assurance Fee Program



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