Skip Navigation LinksICF-DD-N-ICF-DD-CN-CHOS-Provider-Checklist

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 Service

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 Service
  • Remove Service 

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

Required Documents for a Change of Service

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
  • 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
​HS 20​0 (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 ā€“ 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
​Program Plan

Department of Development Services (DDS) Approved Program Plan

Submit a copy of the approved program plan from DDS.

STD 85​0​​ (PDF)​​


Fire Safety Inspection Request ā€‹(if applicable)
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 & Safe​ty (FLS) Inspection approval does not replace this form.​

​
Note: Save a copy of all submitted documents for your records.
Page Last Updated :