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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:

  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Number​

​Chemical Dependency Recovery Hospital

Report of Change Applicati​on Checklist for Change of Location

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 - P​l​​ease submit your d​ocuments in this order

Required Documents for a Change of Location

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
  • 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​
HS 200 (PDF)
Licensure & Certification Application 

[Title 22 California Code of Regulations (CCR) section 79107(b)(4)]

Tip

  • Page 6, Section 6 — An organization must own 100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN)
  • Page 9, Section 5 — When listing the names of individuals with direct or indirect ownership of the facility in Section 5, provide the EIN (do not enter a social security number in this field)

​Supporting Documents

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​

CDPH 609 (PDF)

Bed or Service Request

Top of page:

  • Under the “Existing Beds” category:
    • Include the bed count next to the applicable bed type
  • Under the “Requested Beds” category:
    • Include the new total bed count(s)
    • ​The “Approved Capacity” field should be left blank
​CDPH 709 (PDF)

Client Accommodation Analysis
  • Complete this form in its entirety
  • ​Must be signed
​Supporting Documents 

Floor Plan

Submit a floor plan that describes the requested change including a schematic of the room(s) on CDPH 709

​Supporting Documents 

Construction Documents

[22 CCR section 79105]

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

HS 602 (PDF)


Transfer Agreement

[22 CCR section 79319]

Copy of current written transfer agreement with a General Acute Care Hospital

Tips

  • The Facility Administrator has the authority to sign this form
  • The facility may not have a Facility Provider Number yet, and may be left blank
STD 850 ​(PDF)

Fire Safety Inspection Request

[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


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