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​​​​​
  

For a newly licensed, constructed, or remodeled building, the following is required:

• Title 24 compliance (OSHPD 3 Standards) - a California licensed architect or the local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements:
   
  
• California Building Code (CBC)
• California Fire Code (CFC)
• California Electrical Code (CEC)
• California Mechanical Code (CMC)
• California Plumbing Code (CPC)
• California Administrative Code (CAC)
  

​* CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, is an acceptable form to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by the local building authority or HCAI. ​

• Certificate of Occupancy 

[HSC 1225(c)(3)] [Title 42 Code of Federal Regulations (CFR) sections 485.62(a)(1), 485.723(a)(1)]​

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

​Department of Housing & Community Development (HCD) Insignia

[HSC section 1765.120 through 1765.155]

• Department of Housing and Community Development (HCD) Approval
  

• Copy of HCD Inspection Approval, or

• Copy of HCD Insignia​

​Self-Contained Letter

[HSC sections 1765.120 through 1765.155]

• Submit a letter or statement on cover letter verifying the mobile unit is self-contained
  

• If the mobile unit is not self-contained, HCAI approval is only required if the utility hookups originate or pass through any general acute care hospital building
  

Comprehensive Outpatient Rehab Facility Report ​

Submit the comprehensive outpatient rehab facility report for certifications