HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Chemical Dependency Recovery Hospital

Report of Change Application Checklist for Change of Service

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.

Add Service/Equipment Change
Close/Remove Service

Checklist and Instructions - Please submit your documents in this order

Required Documents to Add Service/Equipment Change

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 Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address) The Department will use the invoice contact email address to invoice the application fee The Department will use the applicant contact email address to send all application correspondence General Contact Information (name, title, phone number, fax, email address, and alternative contact information) The Department will use this information to contact the facility for day-to-day business Emergency Contact Information (name, phone number, fax, email address, alternate email, 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) All Facility Letter Contact Information (name, phone number, fax, and email address) The Department will use this information to send All Facility Letters Facility Contact (Public Use) Information (phone number, fax, email address, and website address) The Department will use this information to store facility contact information for the public Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents Signature
HS 200 (PDF, 1.5MB)	Licensure & Certification Application [Title 22 California Code of Regulations (CCR) section 79101(d)(e)] 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	A.10 - Construction [22 CCR section 79105] Submit evidence of compliance with local building code requirements whether or not construction occurred
Written Request	Supplemental Policy [22 CCR section 79101(d)] Provide a detailed written listing of services offered or provided by the hospital. The detailed written listing shall include but not be limited to: Age range of patients for whom care will be provided Classifications of chemical dependencies to be treated Descriptions of each of the specific elements of the overall treatment program All proposed modifications to existing approved treatment programs
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 of service including a schematic of each room
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. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form.

Required Documents to Close a Facility or Remove a Service

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

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
Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address)

The Department will use the invoice contact email address to invoice the application fee
The Department will use the applicant contact email address to send all application correspondence

General Contact Information (name, title, phone number, fax, email address, and alternative contact information)

The Department will use this information to contact the facility for day-to-day business

Emergency Contact Information (name, phone number, fax, email address, alternate email, 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)

All Facility Letter Contact Information (name, phone number, fax, and email address)

The Department will use this information to send All Facility Letters

Facility Contact (Public Use) Information (phone number, fax, email address, and website address)

The Department will use this information to store facility contact information for the public

Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)

The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents

Signature

HS 200 (PDF, 1.5MB)

Licensure & Certification Application

[Title 22 California Code of Regulations (CCR) section 79101(d)(e)]

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)