HEALTH CARE FACILITY LICENSING AND CERTIFICATION

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

Report of Change Application Checklist for Change of Service

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.

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

Required Documents to Add or Remove a Service

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
Cover Letter	Cover Letter PDHRC: [Health and Safety Code (HSC) section 1763.4] Letter on company letterhead with the following information: License number Facility name and address Facility ID number (if known) Brief description of request: Indicate the type of service you would like to add or remove. If adding the Transitional Health Care Needs Optional Service Unit, please specify your request for this service here 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 Note: For PDHRCs who opt to provide services to individuals 22 years of age and older, the PDHRC must apply and be approved to operate a Transitional Health Care Needs Optional Service Unit by requesting this service as listed above.
HS 200 (PDF, 1.5MB)	Licensure & Certification Application CLHF and PDHRC: [Title 22 of the California Code of Regulations (CCR) section 72201(b)] CLHF: [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 Signature must be from the applicant (Licensee/owner), not the Administrator, unless the owner is the Administrator.
Supporting Documents	A.3 – Type of Change CLHF and PDHRC: [HSC section 1250(i)(2)(A), (B) and (C)] Under Subsection (n.), specify which of the following services the applicant will be providing: CLHF A: Services for individuals, who are mentally alert, physically disabled individuals who may be ventilator dependent CLHF B: Services for individuals who have a diagnosis of terminal illness, a diagnosis of a life-threatening illness; or both CLHF C: Services for individuals who are catastrophically and severely disabled. Services offered to a catastrophically disabled person shall include, but not be limited to speech, physical, and occupational therapy
Supporting Documents	A.10 - Construction CLHF: [HSC section 1267.19] PDHRC: [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
STD 850 (PDF)	Fire Safety Inspection Request CLHF and PDHRC: [22 CCR section 72505] CLHF: [HSC section 1267.13(a)(b)] PDHRC: [HSC section 1761.2] If there is any construction, 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: Save a copy of all submitted documents for your records.

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