HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Referral Agency

Report of Change Application Checklist for Change of Property Owner

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.

Checklist and Instructions

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

Required Documents to Change Property Owner

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 (www.calhospitalprepare.org/post/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 200 (PDF, 1.5MB)	Licensure & Certification Application [Title 22 California Code of Regulations (CCR) section 74105(a)(7)] 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	D.1 - Control of Property [Health and Safety Code (HSC) section 1405(g)] 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.