Intermediate Care Facility/Developmentally Disabled ICF/DD-Habilitativeā
Report of Change Application Checklist for Change of Director of Nursing
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 Director of Nursing
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āForms and Supporting Documentsā
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āāAdditional Instructions
(āāāEach form listed also has instructions on the foāārm)ā
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āCover Letter
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Cover Letterā
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 current person in the role
- 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)ā
- Signature
Tip
- Search the Cal Health Find database for current staff - (https://www.cdph.ca.gov/Programs/CHCQ/LCP/CalHealthFind/pages/home.aspx)ā
Note: Current regulations do not require ICF/DD and ICF/DD-H to have a Director of Nursing. However, provider may submit a Change of Director of Nursing application to CDPH if they have oneā
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āHS 215A (PDF)ā
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āApplicant Individual Information
ICF/DD
and
ICF/DD-H: Health and Safety Code (HSC) section 1422(d)
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 a director of nursing
- 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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HS 215A Facility Information Sheet (PDF)
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Facility Information Sheet
The Director of Nursing 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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āāSupporting Documents
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Resumeā
A resume is required for the Director or Nursingāāā
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