HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Skilled Nursing Facility and Intermediate Care Facility

Report of Change Application Checklist for Change of Location

The following is a list of forms and supporting documents required for a complete application packet. Failure to include every form and document will delay processing or lead to denial.

Checklist and Instructions

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

Required Documents to Relocate a Facility

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 Previous and proposed/new location Contact information (name, title, phone number, and e- mail address) Facility Contact (public phone number, public fax number, public email address, and public webpage). The Facility Contact (Public Use) information is used to store facility contact information for the public. 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, 1.5MB)	Licensure & Certification Application SNF: Title 22 of the California Code of Regulations (CCR) section 72201 ICF: 22 CCR section 73203 Tips: 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.
HS 200 Supporting Documents	D.1 – Control of Property Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee.
Supporting Documents	Floor Plan Submit a floor plan that coincides with your office space.
HS 200 Supporting Documents	A.10 – Department of Health Care Access and Information(HCAI) and/or Certificate of Occupancy SNF and ICF: HSC section 1276 SNF: 22 CCR section 72205 and 72601 ICF: 22 CCR sections 73213, 73601, 73603, and 73213 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 Department of Health Care Access and information (HCAI)
STD 850 (PDF)	Fire Safety Inspection Request SNF: 22 CCR section 72205 ICF: 22 CCR section 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 OSHPD Fire Life & Safety (FLS) Inspection approval does not replace this form.

Medi-Cal Certification Documents

Forms and Supporting Documents

Additional Instructions
(Each form listed also has instructions on the form)

DHCS 9098 (PDF)

Medi-Cal Provider Agreement

Do not leave any questions blank. Enter “same” or “N/A” if not applicable
The mailing address must be the same as reported on the HS 200 form
Notarized signature page is required
Submit the “Acknowledgement” page from the notary public, if applicable

Medicare Certification Documents

Forms and Supporting Documents

Additional Instructions
(Each form listed also has instructions on the form)

CMS 855A (PDF)

Medicare General Enrollment Health Care Provider/ Supplier Application

This application is from the Centers of Medicare and Medicaid Services
The completed application should be mailed directly to the appropriate fiscal intermediary
This document does not go to CAB

Note: Save a copy of all submitted documents for your records.

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