āForms andā Supportingā Documentsā
| āāAdditional Instructions
(āāāEach form listeādā also has instructions on the form)ā
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āCover Letteāār
| 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 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 (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)
- Signatureā
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āHS 200 (PDF, 1.5MBā)
| Licensure & Certification Application (REVISED 7/2023)[Health and Safety Code (HSC) section 1339.41(d)(2) and (6)]
Tips: - Page 3, section A, item 9 ā If the facility, agency, or clinic indicates they operate 24/7/365, complete āb" to indicate the hours of operations for the public. This information is used for surveying purposes.
- Page 3, section B, item 2 āProvide the EIN of the licensee. Do not enter a Social Security number in this field
- Page 6, Section B, item 6 ā 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)
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āSupporting Documents
| Section D - Property Information (only required for new property) 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 Grand 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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āSupporting Documents
| Section A.10 - Health Care Access & Information (HCAI) and/or Certificate of Occupancy Construction (CO) If the facility is newly constructed or a remodeled building, or if this is not a previously licensed facility contact HCAI or the local building authority for Title 24 clearance.
- Hospice Facility located within the physical plant of another facility under the jurisdiction of HCAI [HSC 1339.43(e)(1)]
- Submit HCAI CO, Construction Final (CF) or Substantial Completion (SC)
- Freestanding Hospice Facility located on the site of or is physically connected to a health facility that is under the jurisdiction of HCAI or the local building authority [HSC 1339.43(f)]
- Submit new construction or renovation plans to HCAI for review and approval
- Submit HCAI, CO, CF, or SC
- All other freestanding Hospice Facilities [HSC 1339.43(d)(1) and (2)]
- Shall be under the jurisdiction of the local building department
- Submit CO from local building department ā
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āSupporting Documents
| āFloor Plan
Submit a floor plan that describes the requested change of beds including a schematic of the room(s)
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āSTD 850 (PDF)
| Fire Safety Inspection Request
[HSC section 1339.43(c)(d)(1)]
The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The OSHPD Fire Life & Safety (FLS) Inspection approval does not replace this form.
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