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Forms and Supporting Documents
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Additional Instructions
(Each form listed also has instructions on the form)
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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)
- Licensee physical address
- Brief description of request
- Include end date of prior person in the role and start date for the current person in the role
- Contact information (name, title, phone number, and e-mail address)
- Facility Contact (public phone number, public fax number, public email address, and public webpage). The Facility Contact (Public Use) information is used to store facility contact information for the public.
- 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)
- Signature
Tip
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DS 1852 (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)
Submit a copy of the DS 1852, received from the California Department of Developmental Services, recommending approval of the Administrator
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HS 215A (PDF)
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Applicant Individual Information
Tips:
- Section A — List facility name and business address. Select facility type and type of application
- Section B – List applicant’s legal name, nature of involvement to the facility (administrator), date of birth, driver’s license or state-issued identification number and expiration date, social security number
- Section E — 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 — If answering yes to any question in this section, complete and attach the facility information sheet (section H)
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Applicant Release — 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 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
- Individual’s nature and dates of involvement
- Entity name, type, and Employer Identification Number (EIN)
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Supporting Documents
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Resume
A resume is required for the administrator
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Criminal Record Clearance Submissions
Submit this form only for the new administrator
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Transmittal Application for Criminal Background Investigation
Mail this form to the address indicated on the form
only for the new administrator
Submit this form to CDPH Criminal Background Section (address is listed on the form).
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Request for Live Scan
[HSC section 1575.7]
Mail this form to the address indicated on the form only for the new administrator
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.
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