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Phone: (916) 552-8632

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​​​​​​​​​​​​

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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 Inst​​ructions - Please submit your documents in this order

Required Documents for a Change of Administrator 

Form​s and Supporting​ Documents​​

Additional Instructions

(Each form listed also has instructions on the form)

Cover Letter

Cover L​e​​tter

Letter on company letterhead with the following information:

  • License number
  • Facility name and 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) (
  • 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​
BCIA 8016​ (PDF) 
Request for Live​​ Scan Service 

The BCIA 8016 form is required for an Administrator.​

For out-of-state fingerprint clearance it is necessary to request exemption for Live Scan and have “wet" fingerprints rolled by a local law enforcement agency, contact the Centralized Applications Branch to obtain forms BC119004 and FD-258 at (916) 552-8632 or by e-mail:


CDPH 322 (PDF) 
Transmittal Application for Criminal Record Clearance
(HSC section 1728.1(a)(2)(A))

Submit the CDPH 322 form for the Administrator to the address indicated on the form. 

CDPH 325 (PDF)

Criminal Record Clearance Submissions 

[Health and Safety Code (HSC) section 1728.1(a)(2)(A)) & Affordable Care Act]

Submit the CDPH 325 form for the Administrator. 

HS 215A (PDF)

Applicant Individual Information

(REVISED 7/2023)

(Title 22 California Code of Regulations (CCR) section 74661 (a)(5) & 74665) (HSC section 1728)

This form must be completed for administrators and include signature.


  • Page 2, section B, item 3 — 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 2, section B, item 4 – Provide your Driver's License Number or a State-Issued identification Card Number. Attached a copy of the Driver's License or State-Issued Identification Card for verification. 
  • Page 2, section B, item 5 – The Social Security Number is an identifier, as several people may have the same name. this will ensure each individual is associated with the correct facility or entity  
  • Page 3, section B, item 7 – Administrator must list the number of hours spent at each agency per week. 
  • 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 D; however, the resume must contain all required information requested in section D
  • Page 7, section F — If answering yes to any question in this section, complete Section H, Facility Information Sheet

HS 215A (PDF)

Section H - 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


A resume is only required for the Administrator​​​(s).

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