Online Application PDF Form
Embedded and generated by online system
Facility Information
Department of Health Care Access and Information (HCAI) Certificate of Occupancy/Approval to repopulate
STD 850 – Fire Safety Inspection Request (PDF) or a document that contains the fire inspector’s contact information (name, email, and address)
Floor plan that includes a schematic of the room(s) (if construction has occurred)
Helpful Tips:
When the facility is approved for re-occupancy:
Submit a Change of Certification (CHOC) application for Medi-Cal and Medicare Certification, if applicable.
Submit a Change of Administrator (CHOA) application for Administrator updates.
Submit a Change of Director of Nursing (DON) application for Director of Nursing updates.
Floor plan that includes a schematic of the room(s)
Submit a Change of Governing Board (CHGB) application if there are any updates to the governing board.