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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​​​​​​​

Skilled Nursing Facility and Intermediate Care Facility

Report of Change Application Checklist for Change of Administrator

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 Administrator 

Forms an​d Supporting​ Docume​​nts​​​​

​​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
    • 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 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 (
  • 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 Information 

SNF: Title 22 of the California Code of Regulations (CCR) sections 72211 and 72513

ICF: 22 CCR section 73225 and 73511


  • 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
  • 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 administrator 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 Administrator

Supporting Documents

Professional License

SNF: 22 CCR sections 72211 and 72007

ICF: 22 CCR sections 73003, 73225, and 73511

A copy or printout of current Nursing Home Administrator license issued by the California Board of Examiners of Nursing Home Administrators is required.

Note: Not applicable to a person that has a state civil service classification or a state career executive appointment to perform that function in a state facility.

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