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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:

  • 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​​​​​​​​​​​​​

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Rehabilitation Clinic 

Report of Change Application Checklist for Change of Location

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 - Please submit your documents in this order

Required Documents for a Change of Location

Forms and​​ Supporting​ Documents​

Additional Ins​tructions

(Each form listed al​so has instructions on the form)

Cover Letter

Cov​er Letter

Letter on company letterhead with the following information:

  • License number
  • Facility name and ID number (if known)
  • Brief description of request
  • Previous and proposed/new location
  • Contact information (name, title, phone number, and
    email 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 ​
HS 200 (PDF, 1.5MB) 

Licensure & Certification Application

[Health and Safety Code (HSC) section 1212(a)]

Tip

  • Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions
Supporting Documents

A.10 – California​ Depar​tment of Health Care Access and Information (HCAI) and/or Certificate of Occupancy

[California Building Code (CBC) section 1226] [HSC section 1226]​

For a newly licensed, constru​cted, or remodeled building, the following is required:

  • Title 24 compliance (OS​HPD 3 Standards) - a California licensed architect or the local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements:
     
    • California Building Code (CBC)
    • California Fire Code (CFC)
    • California Electrical Code (CEC)
    • California Mechanical Code (CMC)
    • California Plumbing Code (CPC)
    • California Administrative Code (CAC)

* CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, is an acceptable form to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by a California licensed architect or local building authority.

  • Certificate of Occupancy
​Supporting Documents
D.1 - Control of Prope​​rty

[HSC section 1212(a)(9)]

Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the licensee

​Supporting Documents 
Floor Plan

[HSC section 1212(a)]

Submit a floor plan showing he dimension of each room and the station placement within each room

STD 850 (PDF) 

Fire Safety Inspection Request

[Title 42 Code of Federal Regulation (CFR) section 485.62 (a)(1)] [HSC section and 1225(c)(3)]

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 & Safety (FLS) Inspection approval does not replace this form.



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