• 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 ​
  

[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
  

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