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Phone: (916) 552-8632


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​​​​

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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 - P​lease submit your documents in this order

Required to Relocate a Facility

Forms and Supporting​ Documents​​

​​Additional Instruct​ions

(​​​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)
  • 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 (
  • 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: Title 22 of the California Code of Regulations (CCR) section 72201

ICF: 22 CCR section 73203


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

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