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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​​​​​

General Acute Care Hospitals and Acute Psychiatric Hospitals

Change of Beds

Required Documents

Online Application PDF Form
  • Embedded and generated by online system
General Acute Care Hospital and Acute Psychiatric Beds
  • ​Copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee (Only required when adding beds in previously unlicensed space)
  • Department of Health Care Access and Information (HCAI) Certificate of Occupancy (CO), Construction Final (CF), or Substantial Completion (SC)
  • STD 850 (PDF)​​ form - Fire Safety Inspection Request or a document that contains the fire inspector’s contact information (name, email, and address)
  • Floor plan that includes a schematic of the room(s)
Swing Beds
  • ​​Documentation/letter approval from Centers for Medicare & Medicaid Services (CMS) approving the ​requested number of swing beds
​Distinct Part Skilled Nursing Facility (D/P SNF) Beds*
  • ​Copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee (Only required when adding beds in previously unlicensed space)
  • Department of Health Care Access and Information (HCAI) Certificate of Occupancy (CO), Construction Final (CF), or Substantial Completion (SC)
  • STD 850 (PDF) form - Fire Safety Inspection Request​ or a document that contains the fire inspector’s contact information (name, email, and address)
  • Floor plan that includes a schematic of the room(s)
  • ​HS 400 (PDF) form – Affidavit Regarding Patient Money
  • HS 402 (PDF) form – Surety Bond Verification 
  • HS 602 (PDF) form – Transfer Agreement (if not co-located to hospital)​ 
D/P SNF Beds - Medicare Certification Documents (Only applicable for Medicare Certification)
  • ​CMS 1561 (PDF) form - Health Insurance Benefit Agreement 
  • CMS 671 (PDF) form – Long-Term Care Facility Application for Medicare and Medicaid
  • HS 328 (PDF) form - Notice-Effective Date of Provider Agreement 
  • HHS 690 (PDF) form - Assurance of Compliance (Submit a verification from the Office of Civil Rights displaying submission of this form)
D/P SNF Beds - Medi-Cal Certification Documents (Only applicable for Medi-Cal Certification)
  • DHCS 9098 (PDF) form – Medi-Cal Provider Agreement 
  • DHCS 6207 (PDF) form – Medi-Cal Disclosure Statement (Only submit Section V – Subcontractor Information and Significant Business Transactions) 
  • One of the following Internal Revenue Service tax documents: ​
    • Form 941 – Employer’s Quarterly Federal Tax Return
    • Form 8109-C – FTD Address Change
    • Letter 147-C – EIN Verification Letter​
    • Form SS-4 – Application for Employer Identification Number
  • HS 328​ (PDF) form - Notice-Effective Date of Provider Agreement​
Helpful Tips
  • ​For distinct part (D/P) facilities, submit the application under the main facility and specify the request is for a D/P facility.​
    • ​​​​If the D/P Director of Nursing is different from the hospital, then submit a Director of Nursing (DON) application.
    • ​If the D/P requests to provide supplemental services, change of services (CHOS) application. ​

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