Intermediate Care Facility/Developmentally Disabled-Nursing
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Intermediate Care Facility/Developmentally Disabled-Continuous Nursing
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 or documents will delay processing or lead to denial.
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 Location
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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)
- Brief description of request
- Previous and proposed/new location
- 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/post/california-health-alert-network-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
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HS 200 (PDF, 1.5MB)
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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.
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Supporting Documents
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A.10 - Building Clearance or Certificate of Occupancy
Submit one of the following:
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Evidence of compliance with local building code requirements or
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Certificate of Occupancy issued by the local building authority
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Supporting Documents
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D.1 - Control of Property
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.
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HS 602 (PDF)
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Transfer Agreement
Copy of current written transfer agreement with a hospital or health facility that meets the requirements of the CCR.
Tip:
- The facility administrator may sign this form
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STD 850 (PDF)
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Fire Safety Inspection Request
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 OSHPD Fire Life & Safety (FLS) Inspection approval does not replace this form
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Medi-Cal Certification Documents
Forms and supporting documents
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Additional Instructions
(Each form listed also has instructions on the form)
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DHCS 9098 (PDF)
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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
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CMS 3070G (PDF)
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Intermediate Care Facilities for Individuals with Intellectual Disabilities Survey Report
This is a “survey” report. The applicant only needs to complete the top portion of the form - the remainder will be completed during the survey.
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Note: Save a copy of all submitted documents for your records.