Intermediate Care Facility/Developmentally Disabled ICF/DD-Habilitativeā
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 Instructions - Pālease submit your documents in this order
Required Documents for a Change of Administrator
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Forms anād Supportingā Documeāāntsāāā
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āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
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Cover Letter
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Cover Letter
Letter on company letterhead with the following information
- License number
- Facility name and address
- Facility ID number (if known)
- Brief description of request
- Include end date of prior person in the role and start date for the current person in the role
- āContāact 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: CAHANā (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
Tip
- āSearch the Cal Health Find database for current staff (/Programs/CHCQ/LCP/CalHealthFind/pages/home.aspx)
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DS 1852ā (PDF)
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Health Facility Program Plan Application
ICF/DD
and
ICF/DD-H: Health and Safety Code (HSC) section 1267.7
ICF/DD: Title 22 California Code of Regulations (CCR) section 76307 and 76309
ICF/DD-H: 22 CCR section 76856(a)ā
Submit a copy of the DS 1852, received from the California Department of Developmental Services, recommending approval of the Administrator
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āHS 215A (PDF)ā
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āApplicant Information
ICF/DD: Title 22 California Code of Regulations (CCR) section 76205 (a)(5) and 76225(a)
ICF/DD-H: 22 CCR section 76851(a)(1)
Tips
- Section A ā List facility name and business address. Select facility type and type of application
- Section B ā List applicantās legal name, nature of involvement to the facility (administrator), date of birth, driverās license or state-issued identification number and expiration date, social security number
- Section E ā Submit ten years of employment history, indicating employer name and address, the start and end dates of employment, job title. The applicant may submit a resume in lieu of this section. The resume must contain all required information requested in section E
- Be sure to include every facility where the applicant is a currently an administrator
- Section F ā If answering yes to any question in this section, complete and attach the facility information sheet (section H)
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Applicant Release ā Be sure that applicant signs and dates this section, print name and title
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āHS 215A ā Facility Information Sheetā (PDF)
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Section H ā Facility Information Sheet
The administrator 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 Service. The following must be completed for each facility and/or agency:
- Facility name
- Facility address
- Facility type
- Individualāāāās nature and dates of involvement
- Entity name, type, and Employer Identification Number (EIN)
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Supporting Documentsā
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Resume
A resume is required for the administrator
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āCriminal Record Clearance Submissions
ICF/DD and ICF/DD- H: HSC section 1265.5
ICF/DD: 22 CCR section 76209(a) and 76513(b)
ICF/DD-H: 22 CCR section 76845
- Submit this form only for the new administrator
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āTransmittal Application for Criminal Background Investigation
[HSC sections 1575.7(a)(1) and 1575.7(a)(2)]
Mail this form to the address indicated on the form only for the newadministrator
Submit this form to CDPH Criminal Background Section(address is listed on the form).
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āRequest for Live Scanā
[HSC section 1575.7]
Mail this form to the address indicated on the form
only for the new administratorā
Note: In addition, submit a copy of this form to CDPH Criminal Background Section. Centralized Applications Branch may also request a copy of this form.āāā
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