Skilled Nursing Facility and Intermediate Care Facility
Report of Change Application Checklist for Change of Location
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.
Checklist and Instructions - Pālease submit your documents in this order
Required to Relocate a Facility
Forms and Supportingā Documentsāā
| āāAdditional Instructāions
(āāāEach form listed also has instructions on the form)ā
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āCover Letterā
| Cover Letterāā 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)
- 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)
- Signatureā
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āHS 200 (PDF)
| 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 ā An organization will have its own Federal tax ID number.
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āHS 200 Supporting Documents
| āD.1 ā 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.
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Supporting Documents ā
| āFloor Plan Submit a floor plan that coincides with your office space.
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āHS 200 Supporting Documents
| āA.10 ā 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)ā
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āSTD 850ā (PDF)
| āFire 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.
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Medi-Cal Certification Documents
āForms and Supporting Documents
| āAdditional Instructions
(Each form listed also has instructions on the form)
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āDHCS 9098ā (PDF)
| Medi-Cal Provider Agreement - Do not leave any questions blank. Enter āsameā or āN/Aā if not applicable
- The mailing address must be the same as reported on the HS 200 form
- Notarized signature page is required
- āSubmit the āAcknowledgementā page from the notary public, if applicableā
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Medicare Certification Documents
āForms and Supporting Documents
| āAdditional Instructions
(Each form listed also has instructions āon the form)
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āCMS 855A ā(PDF)
ā
| 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
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