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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

Initial Application

Required Documents

Online Application PDF Form
  • Embedded and generated by online system
Licensee/Business Entity Information 
  • ​Organizational chart displaying the following information: applicant’s owners, directors, board members, corporate officers, LLC members/managers, and partners.
    • ​The organization chart needs to include all entities that have 5% or more direct and indirect ownership 
  • Foreign or out of state corporations, LLCs, and partnerships need to submit Certificate of Qualifications from the California Secretary of State
Entity Organization 
  • ​​Filing Statement from the Secretary of State
  • Please submit the following documents based on the applicable ownership type:
    • Corporation - Submit Articles of Incorporation and By-Laws
    • LLC - Submit Articles of Organization and Operating Agreement
    • Public Agency - Submit Copy of signed Resolution
    • Partnership - Submit Copy of signed Partnership Agreement
  • ​List of Board of Directors​​
Facility Director of Nursing
  • ​Resume for the Director of Nursing
​Facility Property Information - Onsite
  • ​Copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee
  • 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)
Facility Property Information - Offsite (Only applicable for addition of offsite services)
  • ​Copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee
  • CDPH 270​ (PDF) form - Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital 
  • 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)
Mobile Units (Only applicable for addition of mobile units)
  • Documentation/letter approval from the local planning/zoning agency​
  • Department of Health Care Access and Information (HCAI) Certificate of Occupancy (CO), Construction Final (CF), or Substantial Completion (SC)
  • Letter verifying the mobile unit is self-contained (only when applicable) ​
  • Copy of vehicle registration, including ID, vehicle type and manufacturer (Not applicable for modular units)
  • Copy of Department of Housing & Community Development (HCD) Insignia or “Inspection Approval”​
  • STD 850​ (PDF) form - Fire Safety Inspection Request​ or a document that contains the fire inspector’s contact information (name, email, and address)
  • Schematic displaying the location of the mobile unit on the facility property​
Patient Money Affidavit (Only required when applicable)
  • HS 402 (PDF) ​form - Surety Bond Verification 
  • HS 400 (PDF) form - Affidavit Regarding Patient Money
Subcontractor Information (Only Required when applicable)
  • Copy of any written agreement(s) that Licensee/Business Entity has with the subcontractor that relate to its functions/responsibilities​
Facility Information - Medicare Certification Documents (Only applicable for Medicare Certification)
  • CMS 1561 (PDF) form - Health Insurance Benefit Agreement
  • 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) 
Facility Information - Medi-Cal Certification Documents (Only applicable for Medi-Cal Certification)
  • DHCS 9098 (PDF) form - Health Insurance Benefit Agreement
  • DHCS 6207 ​(PDF) form - Notice-Effective Date of Provider Agreement
  • 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​


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