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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​​​​

Intermediate Care Facility/Developmentally Disabled ICF/DD-Habilitative​

Report of Change Application Checklist for Change of Location

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 Location

Forms and Supporting Documents​

​​Additional Instructions

(​​​Each form listed also has instructions on the form)​

​Cover Letter

Cover Letter

Letter on com​pany letterhead with the following information:

  • License number
  • Facility name and address
  • Facility ID number (if known)
  • Brief description of request
  • Previous and proposed/new location
  • 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​
HS 200 (PDF)
Licensure & Certification Application 

ICF/DD: Title 22 California Code of Regulations (CCR) section 76203(a)(5)

ICF/DD-H: 22 CCR section 76844(b)(5)


  • ​Page 6, section B, item 6 — An organization will have its own Federal tax ID number
​Supporting Documents
A.10 - Construction

ICF/DD: 22 CCR section 76213(a)

ICF/DD-H: 22 CCR section 76847(b) and Health and Safety Code (HSC) section 1267.8

Submit one of the following:

  • Evidence of compliance with local building code requirements or
  • Certificate of Occupancy issued by the local building authority

​Supporting Documents

D.1 - Control of Property

ICF/DD: 22 CCR section 76203(a)(3) and 76205(a)(4)

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

HS 602​ (PDF)

Transfer Agreement

ICF/DD: 22 CCR section 76505(a)

ICF/DD-H: 22 CCR section 76909(a)

Copy of current written transfer agreement with a hospital or health facility that meets the requirements of the CCR.


  • The facility administrator may sign this form

STD 850​​ (PDF)​

Fire Safety Inspection Request (not applicable for a CHOW unless there is construction)

[HSC section 1574.7(b)]

[22 CCR section 78409]

The STD 850 form must be sub​mitted 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

​ ​

​​Medi-Cal Certification Documents

Forms and supporting documents​
​Additional Instructions
(Each form listed also has instructions on the form)
DHCS 9098 (PDF)

​​Medi-Cal Provider Agreement​​

  • Do not leave any questions blank. Enter “same” or “N/A” if not applicable
  • The mailing address must be the same as reported on the HS 200 form
  • Notarized signature page is required

Submit the “Acknowledgement” page from the Notary Public, if applicable

CMS 3070G​ (PDF)

Int​ermediate Care Facilities for Individuals with Intellectual Disabilities Survey R​eport

This is a “survey” repo​rt. The applicant only needs to complete the top portion of the form - the remainder will be completed during the survey.

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