HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Intermediate Care Facility/Developmentally Disabled-Nursing
&
Intermediate Care Facility/Developmentally Disabled-Continuous Nursing

Report of Change Application Checklist for Change of Bed

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

Add
Reactivate
Remove
Suspend

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

Required Documents for a Change of Bed

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 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 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 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
STD 850 (PDF)	Fire Safety Inspection Request If there is any construction, 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. Note: An approved STD 850 Fire Safety Inspection Request is not required for bed reduction or suspension if no construction occurred.

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

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