Skip Navigation LinksCLHF-PDHRC-CHMA-Provider-Checklist

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​​

Congregate Living Health Facility and Pediatric Day Health and Respite Care Facility

Report of Change Application Checklist for Change of Mailing Address

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​lease submit your documents in this order

Required Documents for a Change of Mailing Address

Forms and Supporting Documents​

​​Additional Instructions

(​​​Each form listed also has instructions on the form)​

​Cover Lette​​r

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 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.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)

Licensure & Certification Application

CLHF and PDHRC: Title 22 of the California Code of Regulations (CCR) section 72211(c)

CLHF: Health and Safety Code (HSC) section 1267.13(n)

PDHRC: HSC section 1760.4(c)

Tip

  • ​Page 6, section B, item 6 – An organization will have its own Federal tax ID number​
​​
​​
Page Last Updated :