HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Skilled Nursing Facility and Intermediate Care Facility

Report of Change Application Checklist for Change of Director of Nursing

The following is a list of forms and supporting documents required for a complete application packet. Failure to include every form or 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 for a Change of Director of Nursing

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) Licensee physical address Brief description of request Include end date of prior person in the role and start date for current person in the role 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/post/california-health-alert-network-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 Tip Search the Cal Health Find database for current staff - (https://www.cdph.ca.gov/Programs/CHCQ/LCP/CalHealthFind/pages/home.aspx)
HS 215A (PDF)	Applicant Individual Information SNF and ICF: California Health and Safety Code (HSC) section 1422 Title 22 of the California Code of Regulations (CCR) section 72327 Tips Section A — List facility name and business address. Select facility type and type of application Section B – List applicant’s legal name, nature of involvement to the facility, date of birth, driver’s license or state-issued identification number and expiration date, social security number Section E — Submit ten years of employment history, indicating employer name and address, the start and end dates of employment, job title. The applicant may submit a resume in lieu of this section. The resume must contain all required information requested in section E Section F — If answering yes to any question in this section, complete and attach the facility information sheet (section H) Applicant Release – Be sure that applicant signs and dates this section, print name and title
HS 215A Facility Information Sheet (PDF)	Section H - Facility Information Sheet Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency: Facility name Facility address Facility type Individual’s nature and dates of involvement Entity name, type, and Employer Identification Number (EIN)
Supporting Documents	Resume SNF and ICF: Title 22 CCR section 72327 A resume is required for the Director or Nursing Tip Resume must show that the Director of Nursing has at least one year of experience as a Registered Nurse in nursing supervision within the last five years
Supporting Documents	Professional License SNF and ICF: Title 22 CCR section 72327(a) A Registered Nursing License is required for the Director of Nursing. Provide a printout of current Reigstered Nursing License.