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HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Intermediate Care Facility/Developmentally Disabled ​​​
&
Intermediate Care Facility/Developmentally Disabled-Habilitative​

Report of Change Application Checklist for Change of Location

The following is a list of forms and supporting documents required for a complete application packet. Failure to include every form and document will delay processing or lead to denial.

Checklist and Instructions - P​lease submit your documents in this​ order and save a copy of all submitted documents for your records. 

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 company 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

  • ​Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address)

    • The Department will use the invoice contact email address to invoice the application fee

    • The Department will use the applicant contact email address to send all application correspondence

  • ​General Contact Information (name, title, phone number, fax, email address, and alternative contact information)

    • The Department will use this information to contact the facility for day-to-day business

  • Emergency Contact Information (name, phone number, fax, email address, alternate email, 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)

  • ​All Facility Letter Contact Information (name, phone number, fax, and email address)

    • The Department will use this information to send All Facility Letters

  • ​​Facility Contact (Public Use) Information (phone number, fax, email address, and website address)

    • The Department will use this information to store facility contact information for the public

  • ​Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)

    • The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents​

  • Signature​
​HS ​200 (PDF, 1.5MB)

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)

Tip:​

  • ​Page 6, section B, item 6 — An organization will have its own Federal tax ID number

  • Signature must be from the applicant (Licensee/owner), not the Administrator, unless the owner is the Administrator
​Supporting Documents

​A.10 - Building Clearance or Certificate of Occupancy

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 60​2​ (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 hosp​ital or health facility that meets the requirements of the CCR.

Tip:

  • The facility Administrator may sign this form

STD 8​50​​ (PDF)​​

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

ICF/DD: 22 CCR section 76213 and 76509

ICF/DD-H: 22 CCR section 76847(a) and HSC section 1267.8​

Approved STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI 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 909​8 (PDF, 2.9MB)​

​​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 30​70G​ (PDF)

Intermediate Care Facilities for Individuals with Intellectual Disabilities Survey Report​​

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.

Note: Save a copy of all submitted documents for your records. 

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