HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Congregate Living Health Facility and Pediatric Day Health and Respite Care Facility

Report of Change Application Checklist for Change of Location

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 to Relocate a Facility

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 Previous and proposed/new location 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 72201(b)(5)] PDHRC Only: [Health and Safety Code (HSC) section 1267.13(n) and 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.
Supporting Documents	A.7 – Bed Capacity CHLF: [HSC section 1250(i) and 1267.16(c)] For a CLHF with more than six beds for persons who are terminally ill and for persons who are catastrophically and severely disabled: Submit a Conditional Use Permit The Conditional Use Permit must meet the requirements of the City or County in which it is located unless those requirements are waived by the City or County Note: for PDHRCs a conditional use permit is not needed
Supporting Documents	A.10 - Construction CLHF and PDHRC: [HSC section 1267.19] PDHRC: [HSC section 1761.8] Submit one of the following: Evidence of compliance with local building code requirements or Certificate of Occupancy issued by the local building authority Note: CLHFs and PDHRCs are not subject to architectural plan review by the Office of Statewide Health Planning and Development.
Supporting Documents	D.1 - Control of Property CLHF and PDHRC: [HSC sections 1267.13 (n) and 1760.4 (c)] [22 CCR section 72211(a)] 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.
HS 602 (PDF)	Transfer Agreement CLHF and PDHRC: [22 CCR section 72519(a)] [HSC sections 1267.13 (n) and 1760.4(c)] Copy of current written transfer agreement with a hospital that meets the requirements of the California Code of Regulations Tips The facility administrator may sign this form The facility may not have a provider number yet and this line may be left blank
STD 850 (PDF)	Fire Safety Inspection Request (not applicable for a CHOW unless there is construction) [22 CCR section 72505 and HSC section 1267.13(a)(b)] PDHRC Only: HSC section 1761.2 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.
Floor Plan	Floor Plan A floor plan is required showing the level of care in each room and per bed.

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

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