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HEALTH CARE FACILITY LICENSING AND CERTIFICATION

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

Report of Change Application Checklist for Change of Bed

The following is a list of forms and supporting documents required for a complete application packet. Failure to include every form or document will delay processing or lead to denial.

  • ​Add
  • Reactivate
  • Remove
  • Suspend

Checklist and Instructions - P​lease submit your documents in this order and save a copy of all submitted documents for your records.

Required Documents to Add/Reactivate/Remove a Bed(s)

​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 2​00 (PDF, 1.5MB)

Licensure & Certification Application

CLHF and PDHRC: [Title 22 of the California Code of Regulations (CCR) section 72201(b)(2), 72201(b)(6), and 7221(a)]

PDHRC: [Health and Safety Code (HSC) section 1267.13(n) and 1760.4(c)]

Tip

  • Page 6, Section B, item 6 — An organization will have its own Federal tax ID number.
  • Signature must be from the applicant (Licensee/owner), not the Administrator, unless the owner is the Administrator.​

Note: HS 200 is not required for bed suspension. 
​Supporting Documents 

​A.7 – Bed Capacity

CHLF: [HSC section 1250(i) and 1267.16(c)]

For a CLHF with more than six beds for persons who are terminally ill and for persons who are catastrophically and severely disabled:

  • Submit a Conditional Use Permit

  • The Conditional Use Permit must meet the requirements of the City or County in which it is located unless those requirements are waived by the City or County 

Note: For PDHRCs, a conditional use permit is not needed.
Supporting Documents 

A.10 - Construction

CLHF Only: [HSC section 1267.19]

PDHRC Only: [HSC section 1761.8]

If construction occurred or if a newly constructed building:

  • Submit Evidence of Compliance with local building code requirements or;
  • Certificate of Occupancy issued by the local building authority

Note: not required for bed reduction or suspension if no construction occurred
​Supporting Documents

​Floor Plan

CLHF and PDHRC: [HSC section 1267.13 and 1761.8]

Submit a floor plan that describes the requested change of beds including a schematic of the room(s).
​STD ​850 (PDF)​

Fire Safety Inspection Request

CLHF Only: [22 CCR section 72505] [HSC section 1267.13(a)(b)]

PDHRC Only: [HSC section 1761.2]

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.

Note: An approved STD 850 Fire Safety Inspection Request is not required for bed reduction or suspension if no construction occurred​

Note:  Save a copy of all submitted documents for your records.
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