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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​​​​​​​​​
Comprehensive Outpatient Rehabilitation Facility

Report of Change Application Checklist for Change of Location

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 Location

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
  • Previous and proposed/new location
  • Contact information (name, title, phone number, and
    email 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, 1.5MB)​

Licensure & Certification Application
[Title 42 Code of Federal Regulations (CFR) section 485.56]
​Supporting Documents
A.10 – Certificate of Occupancy

[California Building Code (CBC) section 1226]

[42 CFR section 485.62(a)(1)]

For newly constructed or a remodeled building, the following is required:

  • New Certificate of Occupancy (CO) from the local building authority
STD 85​0​ (PDF) 

Fire Safety Inspection Request
[42 CFR section 485.62(a)(1)]

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

​Supporting Documents 

Control of Property ​

Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee


Medicare Certification Documents​

​Forms and Supporting Documents
​Additional Instructions
(Each form listed also has instructions on the form)

CMS 855A (PDF)
Medicare General Enrollment Health Care Provider/ Supplier Application 
  • This application is from the Federal Department of Health and Human Services
  • The completed application should be mailed directly to the appropriate fiscal intermediary​
​Supporting Documents 

Noridian Healthcare Solutions Recommendation of Approval Letter
  • This letter is issued by Noridian Healthcare Solutions
  • The letter should be included with the application packet​

CMS 359 (PDF) 


Comprehensive Outpatient Rehab Facility Report 
​Submit the comprehensive outpatient rehab facility report for certifications

HHS 690​ (PDF)


Assurance of Compliance
  • The Office of Civil Rights (OCR) online portal is: Office for Civil Rights (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf)
  • Once the online submission is completed, an electronic notification from OCR stating the Assurance of Compliance form was submitted successfully will be received by the applicant
  • Submit a copy of this notification
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