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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​​​​​​​

Correctional Treatment Center 

Report of Change Application Checklist for Change of Administrator

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 - Please submit your documents in this order

Required Documents for a Change of Administrator 

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
  • Licensee physical address
  • Facility ID number (if known)
  • Brief description of request
  • Contact information (name, title, phone number, and e-mail 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 215A (PDF)

Applicant Individual Information
[Title 22 California Code of Regulation (CCR) section 79591]

The form must be completed and signed for the following individual(s):

  • Administrator of the facility

Tips

  • Section B – List applicant’s legal name, nature of involvement to the facility, date of birth, driver’s license or state-issued identification number and expiration date, social security number
  • Section E — Submit ten years of employment history, indicating the start and end dates of employment, job title, employer name and address. The applicant may submit a resume in lieu of completing section E; however, the resume must contain all required information requested in section E
  • Section F — If answering yes to any question in this section, complete and attach the facility information sheet (section H)

Supporting Documents

Facility Information Sheet
[22 CCR section 79777]

The Administrator must complete and submit the Facility Information sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency:

  • Facility name   
  • Facility address
  • Type of facility
  • Type of business entity (include EIN Number)
  • Individual’s nature of involvement
  • Individual’s dates of involvement
  • This Sheet must also include any facilities licensed by the California Department of Social Service

Supporting Documents

Resume

A resume is only required for the Administrator(s)

Supporting Documents

Governing Board Letters

[22 CCR section 79773]

Submit a Governing Board Letter indicating the Appointment of the Administrator​

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