HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Skilled Nursing Facility and Intermediate Care Facility

Report of Change Application Checklist for Change of Bed

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.

Add
Reactivate
Remove
Suspend

Checklist and Instructions

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

Required Documents to Add/Reactivate/Removed Bed(s)

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 Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address) The Department will use the invoice contact email address to invoice the application fee The Department will use the applicant contact email address to send all application correspondence General Contact Information (name, title, phone number, fax, email address, and alternative contact information) The Department will use this information to contact the facility for day-to-day business Emergency Contact Information (name, phone number, fax, email address, alternate email, 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) All Facility Letter Contact Information (name, phone number, fax, and email address) The Department will use this information to send All Facility Letters Facility Contact (Public Use) Information (phone number, fax, email address, and website address) The Department will use this information to store facility contact information for the public Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) The Department will use this information to correspond with the facility’s Privacy/Compliance Officer regarding medical breach incidents Signature
HS 200 (PDF, 1.5MB)	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
Supporting Documents	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
Supporting Documents	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.
STD 850 (PDF)	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.
CDPH 609 (PDF)	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