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Forms and Supporting Documents
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Additional Instructions
(Each form listed also has instructions on the form)
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Cover Letter
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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
- Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address)
General Contact Information (name, title, phone number, fax, email address, and alternative contact information) Emergency Contact Information (name, phone number, fax, email address, alternate email, and phone number that will receive text messages)
CAHAN (https://www.calhospitalprepare.org/cahan)
All Facility Letter Contact Information (name, phone number, fax, and email address) Facility Contact (Public Use) Information (phone number, fax, email address, and website address) Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) Signature
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HS 200 (PDF, 1.5MB)
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Licensure & Certification Application
SNF and ICF: Health and Safety Code (HSC) section 1271.1
SNF: Title 22 of the California Code of Regulations (CCR) sections 72201 and 72211
ICF: 22 CCR sections 73203 and 73214
Tips:
Page 2, Section A, item 7 — Enter Current and Proposed Bed Capacity
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.
Note: HS 200 is not required for bed suspension
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Supporting Documents
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Departments of Health Care Access and Information (HCAI) approval document of the completed construction (Certificate of Occupancy, Certificate of Substantial Compliance or Construction Final)
SNF and ICF: HSC section 1276 & 1275
SNF: 22 CCR section 72205, 72601, 72607, and 72603
ICF: 22 CCR section 73213, 73601, and 73605
If this is a newly constructed and/or remodeled building, or if this is not a previously licensed facility (i.e., existing building with no construction or remodeling required) applicant needs to contact the HCAI at the following website for Title 24 clearance:
HCAI (https://hcai.ca.gov/)
Note: HCAI approval certificate is not required for bed reduction or suspension if no construction occurred
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Supporting Documents
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Floor Plan
Submit a floor plan that describes the requested change of beds including a schematic of the room(s). Must specify bed name and/or bed number and room name and/or room number.
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STD 850 (PDF)
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Fire Safety Inspection Request
SNF: 22 CCR section 72205 and 72607
ICF: 22 CCR sections 73213
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.
Note: an approved STD 850 Fire Safety Inspection Request is not required for bed reduction or suspension if no construction occurred.
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Bed or Service Request
Complete the columns marked “Existing Beds” and “Existing Services” and the columns marked “Requested Beds” and “Requested Services”
Note: CDPH 609 is not required for bed suspension
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