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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 Centers

Initial Application Checklist 

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.

  • Initial License

Checklist and Instructions - P​lease submit your documents in this order

Required Documents for an Initial License

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:

  • 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)
  • Sig​nature
HS 200 (PDF)

Licensure & Certification Application 
[Title 22 California Code of Regulations (CCR) section 79581]
​Supporting Documents

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

Contact HCAI or the local building authority for Title 24 clearance

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

  • Submit a HCAI Certificate of Occupancy or Construction Final

​Supporting Documents

B.3 Organizational Chart – Owner Type

[22 CCR sections 79779(d)]

Submit an organizational chart for the public agency. The organizational chart needs to display the following:​

  • Applicant’s directors, board members and officers
​​​Note: Submit the HS 215A form for each of these individuals
  • Parent company of applicant, if applicable, and all of the licensed agencies/facilities it is operating - see B.6

HS 215A (PDF)​

Applicant Individual Information

[22 CCR sections 79629, 79775, 79777]​

This form must be completed and signed for the following individuals:

  • Administrator of the facility
  • Medical Director
  • Director of Nursing
  • Applicant
    • ​Directors, board members, officers (Chief Executive Officer, President, Chief Operating Officer, Chief Financial Officer)
  • Page 2, section B — The date of birth is an identifier, as several people may have the same name. This will ensure that each individual is associated with the correct facility or entity
  • ​Page 5, 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
  • Page 7, section F — If answering yes to any question in this section, complete Section H: Facility Information Sheet
​Supporting Documents 
Facility Information Sheet​

Each individual 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

Supporting Documents​


[22 CCR sections 79777, 79629 and 79775]

A resume is required for the Administrator, Director of Nursing and Medical Director

​Supporting Documents
Governing Board Letter

[22 CCR section 79773]

Submit a Governing Board Letter indicating the Appointment of the Administrator

​Supporting Documents 
Administrative Qualifications

[22 CCR section 79777(d)]

The Administrator shall submit a copy of one of the following qualifications:

  • Master’s degree in Health Services Administration
  • Master’s degree in a health-related field
  • Bachelor’s degree in a health-related field
  • State civil service appointment as a Correctional Health Services Administrator
​Supporting Document
Professional Licenses/ Certificates

[22 CCR sections 79629(a), 79775(a)]

  • An active registered medical license is required for the Medical Director
  • An active registered nursing license is required for the Director of Nursing
  • Provide a printout of the current license from the
    Department of Consumer Affairs

HS 309 1st Page​ (PDF)

Administrative Organization

[22 CCR section 79773]

Along with the HS 309, the following supporting documents according to organizational type must be submitted:

HS 309 2nd Page​ (PDF)

Organizational Structure 

Only complete fields that are applicable to applicant’s entity type​

​Supporting Documents

Public Agency

[22 CCR section 79773]

Copy of signed Resolution

​Supporting Documents

Public Agency 

Submit a web-based map

STD 850​​ (PDF)​

Fire Safety Inspection Request

[Title 22 CCR sections 79583, 79825]

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 Service Request

[Title 22 CCR section 79581(c)]

  • ​Complete the columns marked “Requested Beds” and “Requested Services”
  • List of services to be offered (only if additional space is needed to input all services)
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