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 Contact Us

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​​

Intermediate Care Facility/Developmentally Disabled ICF/DD-Habilitative

Report of Change Application Checklist for Change of Service

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 Service

Forms and Supporting Documents​

​​Additional Instructions

(​​​Eac​​h fo​​rm 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
  • 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 and ICF/DD-H: Title 22 California Code of Regulations (CCR) section 76225(a) and Health and Safety Code (HSC) section 1265


  • Page 6, section B, item 6 — An organization will have its own Federal tax ID number
​Supporting Documents
A.10 Building Clearance or Certificate of Occupancy

ICF/DD and ICF/DD-H: HSC section 1267.8

ICF/DD: 22 CCR section 76213(a)

ICF/DD-H: 22 CCR section 76847(b)

If construction occurred or if a newly constructed building:

  • Submit evidence of compliance with local building code requirements or;
  • Certificate of Occupancy issued by the local building authority
​Program Plan

Department of Development Services (DDS) Approved Program Plan

ICF/DD and ICF/DD-H: 22 CCR section 76307 and HSC section 1267.7

ICF/DD-H: 22 CCR section 76856

Submit a copy of the approved program plan from DDS.

STD 850​​ (PDF)​

Fire Safety Inspection Request ​(if applicable)

ICF/DD: 22 CCR section 76213

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

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 HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form.​

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