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 - Pālease 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
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Forms and Supporting Documentsā
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āāAdditional Instructions
(āāāEach formā listed also has instructions on the form)ā
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āCover Letter
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Cover Letterā
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
- Contact information (name, title, phone number, and e- mail address)
- Facility Contact (public phone number, public fax number, public email address, and public webpage). The Facility Contact (Public Use) information is used to store facility contact information for the public.ā
- 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
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.
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āHS ā200 (PDF, 1.5MB)
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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 ā 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.
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āSupporting Documents
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āA.3 ā
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:
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CLHF
A: Services for individuals, who are mentally alert, physically disabled individuals who may be ventilator dependent
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CLHF
B: Services for individuals who have a diagnosis of terminal illness, a diagnosis of a life-threatening illness; or both
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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
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āSupporting Documents
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āA.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;
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Certificate
of
Occupancy issued by the local building authority
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STD 8ā50āā (PDF)āā
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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.ā
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