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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​​​​​

Home Health Agency

Report of Change Application Checklist for Change of Director of Patient Care Services

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 - Please submit your documents in this order

Required Documents for a Change of Director of Patient Care Services

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:

  • License number

  • Facility name and ID number (if known)

  • Brief description of request

  • Contact information (name, title, phone number, and email address)

  • Emergency Contact In​​formation (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

HS 215A (PDF)

Applicant Individual Information (REVISED 7/2023) 

[Title 22 California Code of Regulations (CCR) section 74661 (a)(5) & 74665, (Health and Safety Code (HSC) section 1728)]

This form must be completed for the following individuals and include original signatures:

  • Administrator and Director of Patient Care Services of the facility

  • Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization 

 ​Each individual having a beneficial interest of five  percent or more in the applicant organization and/or parent organization 


  • 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 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​
​Supporting Documents 

Section H - Facility Information

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 required for the Administrator, Director of Patient Care Services, and Medical Director or contracted Medical Director

​​Supporting Documents 

​Section D - Professional Licenses/ Certificates​​

[Title 22 CCR section 74703]​

An active registered nursing license is required for the Director of Patient Care Services. Provide a printout of the current license from the Department of Consumer Affairs. (

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