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Phone: (916) 552-8632

For application status requests, please include the following in your email:

  • Application ID (if applicable)
  • 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 Bed

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 Bed

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
  • 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 (
  • 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)

Licensing & Certification Application

[Title 22 California Code of Regulations (CCR) section 79581]


  • Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions
Supporting Documents 

A.10 – California Department of Health Care Access and Information (HCAI) and/or Certificate of Occupancy [22 CCR sections 79583, 79819 and 79821]

Contact HCAI or the local building authority for Title 24 clearance.

If the facility is a newly constructed or remodeled building, submit the following:

  • Submit a HCAI Certificate of Occupancy or Construction Final
Supporting Documents 

Floor Plan

Submit a floor plan that coincides with your office space

STD 850 (PDF)

Fire Safety Inspection Request

[22 CCR sections 79583 and 79525]

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

CDPH 609 (PDF)

Bed or Services Request
  • For new facilities or initial licensure, complete the columns marked “Requested Beds” and “Requested Services”
  • For currently licensed facilities or Change of Ownership complete the columns marked “Existing Beds” and “Existing Services” and the columns marked “Requested Beds” and “Requested Services”

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