× The federal government has shut down due to the failures of the President and Congress to continue government funding. Millions of Californians receiving benefits from state programs may be impacted. For now, California’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) will continue to provide services and enroll eligible families as long as funding is available. No new federal funding to California WIC will be provided until the President and Congress take action. Families should continue to use their WIC benefits and attend their WIC appointments. This information is subject to change, so please monitor the California WIC website for updates.

Please be wary of potential highly partisan political messaging while visiting federal government websites for information related to the federal government shutdown.

Skip Navigation LinksSNF-ICF-CHOS-Provider-Checklist

Top Menu
Left Menu

HEALTH CARE FACILITY LICENSING AND CERTIFICATION​​

Skilled Nursing Facility and Intermediate Care Facility

Report of Change Application Checklist for Change of Service

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.

  • ​Add Service
  • Remove Service 

Checklist and Instructions

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

Required Documents to Add or Remove a Service

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
  • 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 20​0 (PDF, 1.5MB)​

Licensure & Certification Application

SNF and ICF: Health and Safety Code (HSC) sections 1252, 1253, and 1268

SNF: Title 22 of the California Code of Regulations (CCR) sections 72201 and 72401

ICF: 22 CCR sections 73203, 73391, 73417, and 73425

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.
​Supporting Documents

Department 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 sections 1276

SNF: 22 CCR sections 72205, 72601, and 72603

ICF: 22 CCR sections 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 California Department of Health Care Access and Information (HCAI) at the following website for Title 24 clearance: HCAI

Note: HCAI Approval (PDF, 1.5MB)  is required for portable bedside hemodialysis
Supporting Documents

Fully Executed Provider Agreement

SNF and ICF: HSC section 1267

SNF: 22 CCR section 72511

ICF: 22 CCR section 73505

If services are provided by a contractor, submit a copy of fully executed agreement between the contractor and the licensee

STD 8​50​​ (PDF)​

Fire Safety Inspection Request

SNF: 22 CCR sections 72205

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 OSHPD Fire Life & Safety (FLS) Inspection approval does not replace this form.
​CDPH 60​9 (PDF)

 ​Bed or Service Request

For currently licensed facilities complete the columns marked “Existing Beds” and “Existing Services” and the columns marked “Requested Beds” and “Requested Services”
Supporting Documents​

 ​Application for Supplemental Services

SNF: 22 CCR sections 72401 and 72211

ICF: 22 CCR section 73445

Include the forms corresponding with the type of service SNF is requesting to add to the license

  • CDPH 242: Chronic Dialysis Service
  • CDPH 246: Application for Outpatient Service
  • CDPH 259: Rehabilitation (ICF ONLY)
  • CDPH 260: Occupational Therapy Service
  • CDPH 261: Physical Therapy Service
  • CDPH 262: Speech Pathology and/or Audiology Service
  • CDPH 255: Social Work Service
All the forms required for SNF services can also be requested for ICF in addition to the documents requested below:
  • ​CDPH 609: Special Treatment Program Service​
​ ​
Note: Save a copy of all submitted documents for your records. 
​
​
​
Page Last Updated :