Intermediate Care Facility/Developmentally Disabled-Nursing
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Intermediate Care Facility/Developmentally Disabled-Continuous Nursing
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
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Forms and Supporting Documents
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Additional Instructions
(Each form listed also has instructions on the form)
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Cover Letter
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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) General Contact Information (name, title, phone number, fax, email address, and alternative contact information) 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://calhospital.org/calhospitalprepare)
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) Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) Signature
Tip:
Note: Current regulations do not require ICF/DD-N and ICF/DD-CN to have a Director of Nursing. However, provider may submit a Change of Director of Nursing application to CDPH if they have one
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HS 215A (PDF)
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Applicant Individual Information
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 (administrator), 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
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HS 215A Facility Information Sheet (PDF)
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Section H - Facility Information Sheet
The Director of Nursing 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 Service. 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)
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Supporting Documents
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Resume A resume is required for the Director or Nursing
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Note: Save a copy of all submitted documents for your records.