Application Request for Intermediate Care Facilities for the Developmentally Disabled
These instructions are to assist you in preparing a 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 for the following facilities:
- Intermediate Care Facility/Developmentally Disabled (ICF/DD)
- Intermediate Care Facility/Developmentally Disabled - Habilitative (ICF/DD-H)
- Intermediate Care Facility/Developmentally Disabled - Nursing (ICF/DD-N)
When preparing your application package, please use the following applicable checklist(s):
A state license is required to operate an ICF/DD, ICF/DD-H, or ICF/DD-N facility in California, which are defined as:
- ICF/DD means "a facility that provides 24-hour personal care, habilitation, developmental, and supportive health services to developmentally disabled clients whose primary need is for developmental services and who have a recurring but intermittent need for skilled nursing services," pursuant to Health and Safety (H&S) Code Section 1250(g).
- ICF/DD-H means "a facility with a capacity of 4 to 15 beds that provides 24-hour personal care, habilitation, developmental, and supportive health services to 15 or fewer developmentally disabled persons who have intermittent recurring needs for nursing services, but have been certified by a physician and surgeon as not requiring availability of continuous skilled nursing care," pursuant to H&S Code Section 1250(e).
- ICF/DD-N means "a facility with a capacity of 4 to 15 beds that provides 24-hour personal care, developmental services, and nursing supervision for developmentally disabled persons who have intermittent recurring needs for skilled nursing care but have been certified by a physician and surgeon as not requiring continuous skilled nursing care. The facility shall serve medically fragile persons who have developmental disabilities or demonstrate significant developmental delay that may lead to a developmental disability if not treated," pursuant to H&S Code Section 1250(h).
An application package is required for: (1) a new (initial) ICF/DD, ICF/DD-H, or ICF/DD-N 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 Branch (CAB), pursuant to Title 22 of the California Code of Regulations (CCR) Sections 76203 and 76844. All other changes (besides a CHOW) must also be reported to CAB in writing within 10 days of the change, pursuant to Title 22 CCR Sections 76225 and 76851. These 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 certification of an ICF/DD, ICF/DD-H, or ICF/DD-N facility. 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 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 an ICF/DD, ICF/DD-H, or ICF/DD-N, which is posted on the L&C Facility Fee website.
The application fee will not be returned if the application is withdrawn or denied pursuant to Title 22 CCR Sections 76211(a)(2) and 76846(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 National Plan and Provider Enumeration System website.
If your facility wants to provide services to Medi-Cal beneficiaries (under Title 19), you will need an additional certification survey that is unannounced and conducted by one of our L&C DOs. 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.
In addition, you must be in compliance with state licensing laws and federal conditions of participation.
Initial Licensing Survey
An initial licensing survey is part of the application process for "new" ICF/DD, ICF/DD-H, or ICF/DD-N applications. The initial licensing survey is a scheduled survey conducted by L&C DOs.
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 CAU 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. 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.
Quality Assurance Fee Program
The Department of Health Care Services (DHCS) recommends to facilities that apply for a Change of Ownership with CDPH to further review the information and collection process on the Quality Assurance Fee (QAF) program website.
Unpaid QAF shall become the liability of the purchaser. For information regarding a specific facility, the current owner must provide to DHCS authorization to release information before the facility will be discussed with the purchaser. Any questions should be addressed to Jamie Carroll at (916) 650-0530.
Health and Safety Code Sections 1324.20 through 1324.30 authorize the DHCS to implement a QAF program for Freestanding and Skilled Nursing Facility Level-B (FS/NF-B) and Freestanding Skilled Adult Subacute Nursing Facilities (FSSA/NF-B). The QAF is imposed on all FS/NF-B and FSSA/NF-B, except those that are exempt pursuant to Health and Safety Code Section 1324.20(b). Health and Safety Code Sections 1324 through 1324.14 govern the QAF imposed on ICF/DD), ICF/DD-H and ICF/DD-N.
The purpose of the QAF program is to provide additional reimbursement for, and to support quality improvement efforts in, the above listed facilities. The QAF is assessed on each facility on an annual basis irrespective of any changes in ownership, interest or control, or the transfer of any portion of the assets of a facility to another.
If you have any questions, please contact the CAB, at (916) 552-8632 or by e-mail at CAB@cdph.ca.gov.