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)
• 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​

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

Note: HCAI approval certificate is not required for bed reduction or suspension if no construction occurred

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