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HEALTH CARE FACILITY LICENSING AND CERTIFICATION

 Contact Us

Phone: (916) 552-8632
Email: CAB@cdph.ca.gov     

For application status requests, please include the following in your email:

  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Number​​​​

Intermediate Care Facility/Developmentally Disabled-Nursing
ICF/DD-Continuous Nursing​​​

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 - P​lease submit your documents in this order

Required Documents for a Change of Director of Nursing

Forms and Supporting Documents​

​​Additional Instructions

(​​​Each form listed also has instructions on the fo​​rm)​

​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
    • 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)​
  • Signature

Tip

  • Search the Cal Health Find database for current staff - (https://www.cdph.ca.gov/Programs/CHCQ/LCP/CalHealthFind/pages/home.aspx)​
Note: Current regulations do not require ICF/DD-N and ICF/DD-CN to have a Director of Nursing. However, provider may submit a Change of Director of Nursing application to CDPH if they have one

HS 215A (PDF)​

Applicant Individual Information 

ICF/DD and ICF/DD-H: Health and Safety Code (HSC) section 1422(d)

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 a director of nursing
  • Section F — If answering yes to any question in this section, complete and attach the facility information sheet (section H)
  • Applicant Release — Be sure that applicant signs and dates this section, print name and title

HS 215A Facility Information Sheet (PDF)

Section H - 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
  • Individual’​​​s nature and dates of involvement
  • Entity name, type, and Employer Identification Number (EIN)
​​Supporting Documents

Resume​

A resume is required for the Director or Nursing​​​​



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