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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​​​​​​

Home Health Agency

Report of Change Application Checklist for Change of Property Owner

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 - P​lease submit your documents in this order

Required Documents for a Change of Property Owner

Forms and Supporting​​​ Documents​​

​​Additional Instructions

(​​​Ea​​ch fo​​rm listed also has instructions on the form)​

​Cover Letter

Cover Letter

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 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) (https://www.calhospitalprepare.org/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​)

Licensure & Certification Application

(REVISED 7/2023) [Title 22 California Code of Regulation (CCR) section 74661 (Health and Safety Code (HSC) 1728)]

Tips:

  • Page 3, section A, item 9 – If the facility, agency, or clinic indicates they operate 24/7/365, complete “b" to indicate the hours of operations for the public. This information is used for surveying purposes.
  • Page 3, section B, item 2 –Provide the EIN of the licensee. Do not enter a Social Security number in this field.
  • Page 6, section B, item 6 — An organization must own 100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN)
​Supporting Documents

Section D - Property Information 

Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee

  • If the licensee owns the property, submit a signed copy of the Grant Deed, or Bill of Sale  
  • If the licensee rent, lease, or sublease, submit the signed copy of the agreement (i.e., rental agreement and/or master lease between the property owner/manager and the perspective licensee) 

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