HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Adult Day Health Center

Report of Change Application Checklist for Change of Bed (Capacity)

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 Bed (Capacity)

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 Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address) The Department will use the invoice contact email address to invoice the application fee The Department will use the applicant contact email address to send all application correspondence General Contact Information (name, title, phone number, fax, email address, and alternative contact information) The Department will use this information to contact the facility for day-to-day business Emergency Contact Information (name, phone number, fax, email address, alternate email, 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) All Facility Letter Contact Information (name, phone number, fax, and email address) The Department will use this information to send All Facility Letters Facility Contact (Public Use) Information (phone number, fax, email address, and website address) The Department will use this information to store facility contact information for the public Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents Signature
Pre-Screened Approval Letter	Pre-Screened Approval Letter Required for Community-Based Adult Services (CBAS) Programs Only This letter is issued by the California Department of Aging and only required for CBAS participants Not required for Program of All-inclusive Care for the Elderly (PACE) Organizations
HS 200 (PDF, 1.5MB)	Licensure & Certification Application [Health and Safety Code (HSC) section 1575.1 and 1575.2] [Title 22 California Code of Regulations (CCR) section 78205] Tip 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	A.10 - Construction [22 CCR section 78501(a)(1) and (b), 78227(1)] If construction occurred or if a newly constructed building: Submit evidence of compliance with local building code requirements or; Certificate of Occupancy issued by the local building authority Note: ADHCs are not subject to architectural plan review by the Department of Health Care Access and Information (HCAI).
CDPH 609 (PDF)	Bed or Service Request [22 CCR section 78221] Top of page: Under the “Existing Beds” category: Include the bed count next to the applicable bed type Under the “Requested Beds” category: Include the new total bed count(s) The “Approved Capacity” field should be left blank Tips Approved Capacity: Do not complete this section - For CAB use only To remove a service from your license, in the “Requested Services” column, make sure the service you want removed is unchecked
STD 850 (PDF)	Fire Safety Inspection Request [HSC section 1574.7(b)] [22 CCR section 78409] 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 HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form.
Map and Floor Plans	Map and Floor Plans [22 CCR sections 78205(a)(8), 78501, 78503, and 78505] Submit a map identifying the ADHC service area The physical plan accommodations, general building requirements and space requirements Submit a detailed and legible floor plan of the “existing” or “proposed” changes indicating square footage and basic services. The floor plan should indicate: Office Space Bathrooms (e.g., number of toilets and urinals in each bathroom) Entrances, emergency exits, and outdoor areas

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

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