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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​​​​​​​



Skilled Nursing Facility and Intermediate Care Facility

Report of Change Application Checklist for Change of Bed

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.

  • ​Add/Reactivate
  • Remove
  • Suspend

Checklist and Instructions - P​lease submit your documents in this order

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

Forms and Supporting​ Documents​

​​Additional Instructions

(​​​Each form liste​d​ also has instructions on the form)​

​Cover Lette​​r

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​
HS 200 (PDF)

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 6, Section B, item 6 — An organization will have its own Federal tax ID number.

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

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)

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


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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