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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​​​​​​​

Chronic Dialysis Clinic 

Report of Change Application Checklist for Change of Bed

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 - Please submit your documents in this order

Required Documents for a Change of Bed

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
  • Contact information (name, title, phone number, and email 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
HS 200 (PDF, 1.5MB)

Licensure & Certification Application

[Health and Safety Code (HSC) section 1212(a)] [Title 42 Code of Federal Regulation (CFR) section 494.60(c)]

Tip

  • Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions 
Supporting Documents 

A.10 – California Department of Health Care Access and Information (HCAI) and/or Certificate of Occupancy

HCAI and Local Building Authority
One of the two documents are required:

For a newly licensed, constructed, or remodeled building, the following is required:

  • Title 24 compliance (OSHPD 3 Standards) - a California licensed architect or the local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements:
     
    • California Building Code (CBC)
    • California Fire Code (CFC)
    • California Electrical Code (CEC)
    • California Mechanical Code (CMC)
    • California Plumbing Code (CPC)
    • California Administrative Code (CAC) 
* CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, is an acceptable form to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by the local building authority or HCAI. 

  • Certificate of Occupancy 
Supporting Documents

D.1 – Control of Property

[HSC section 1212 (a)(9)]

Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the facility for licensed facilities only

Supporting Documents 
Floor Plan

[HSC section1212 (a)(9)]

Submit a floor plan showing the dimensions of each room and the station placement within each room

STD 850 (PDF)

Fire Safety Inspection

[Health and Safety Code (HSC) sections 1225(c)(1), 1267.13(b),

494.60 (d)(3)]

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 HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form

Medicare Certification Documents 

Forms andSupportingDocuments

AdditionalInstructions

(Each form listed also has instructions on the form)

CMS 3427 (PDF) 

End Stage Renal Disease Application and Survey and Certification Report

[State Operational Manual section 2274B]

Complete and provide all information on section 1 thru 24 (except section 2)



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