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
• Previous and proposed/new location
• 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.c​alhospitalprepare.org/cahan)
  
• Signature​
  

​D.1 - Control of Property

Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee​

• Complete this form in its entirety
• ​Must be signed

[22 CCR section 79105]

Submit evidence of compliance with local building code requirements whether or not construction occurred

[22 CCR section 79105]

The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form