HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Congregate Living Health Facility and Pediatric Day Health Respite Facility

Report of Change Application Checklist for Change of Mailing Address

The following is a list of forms and 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 Mailing Address

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

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. Indicate if the change of the mailing address is for the Licensee or the facility.
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

HS 200 (PDF, 1.5MB)

Licensure & Certification Application

CLHF and PDHRC: Title 22 of the California Code of Regulations (CCR) section 72211(c)

CLHF: Health and Safety Code (HSC) section 1267.13(n)

PDHRC: HSC section 1760.4(c)

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.

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

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