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Phone: (916) 552-8632

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

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

Referral Agency

Report of Change Application Checklist for Change of Agency Manager 

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 Agency Manager 

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 (only applicable for CHOW)
  • Facility name and ID number (if known)
  • Brief description of request
  • Previous and proposed/new location
  • 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 (
  • 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 
  • ​Search the Cal Health Find database for current staff - (

HS 215A (PDF)​

Applicant Individual Information 

[Health and Safety Code (HSC) section 1409.3(b)] and [Title 22 California Code of Regulations (CCR) section 74119(b)]


  • 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, 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 agency manager
  • 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)

Facility Information Sheet

The Agency Manager 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


A resume is required for the Agency Manager​

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