HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Skilled Nursing Facility and Intermediate Care Facility

Report of Change Application Checklist for Change of Service

The following is a list of forms and supporting documents required for a complete application packet. Failure to include every form and document will delay processing or lead to denial.

Add Service
Remove Service

Checklist and Instructions

Please submit your documents in this order and save a copy of all submitted documents for your records.

Required Documents to Add or Remove a Service

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 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 SNF and ICF: Health and Safety Code (HSC) sections 1252, 1253, and 1268 SNF: Title 22 of the California Code of Regulations (CCR) sections 72201 and 72401 ICF: 22 CCR sections 73203, 73391, 73417, and 73425 Tips: 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	Department of Health Care Access and Information (HCAI) Approval Document of the Completed Construction (Certificate of Occupancy, Certificate of Substantial Compliance or Construction Final) SNF and ICF: HSC sections 1276 SNF: 22 CCR sections 72205, 72601, and 72603 ICF: 22 CCR sections 73213, 73601, and 73605 If this is a newly constructed and/or remodeled building, or if this is not a previously licensed facility (i.e., existing building with no construction or remodeling required) applicant needs to contact the California Department of Health Care Access and Information (HCAI) at the following website for Title 24 clearance: HCAI (https://hcai.ca.gov/) Note: HCAI Approval (PDF, 1.5MB) is required for portable bedside hemodialysis (https://hcai.ca.gov/wp-content/uploads/2021/12/9_Mobile-Dialysis-Unit-Installation_12-22-2021_Revised.pdf)
Supporting Documents	Fully Executed Provider Agreement SNF and ICF: HSC section 1267 SNF: 22 CCR section 72511 ICF: 22 CCR section 73505 If services are provided by a contractor, submit a copy of fully executed agreement between the contractor and the licensee
STD 850 (PDF)	Fire Safety Inspection Request SNF: 22 CCR sections 72205 ICF: 22 CCR sections 73213 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 OSHPD Fire Life & Safety (FLS) Inspection approval does not replace this form.
CDPH 609 (PDF)	Bed or Service Request For currently licensed facilities complete the columns marked “Existing Beds” and “Existing Services” and the columns marked “Requested Beds” and “Requested Services”
Supporting Documents	Application for Supplemental Services SNF: 22 CCR sections 72401 and 72211 ICF: 22 CCR section 73445 Include the forms corresponding with the type of service SNF is requesting to add to the license CDPH 242: Chronic Dialysis Service CDPH 246: Application for Outpatient Service CDPH 259: Rehabilitation (ICF ONLY) CDPH 260: Occupational Therapy Service CDPH 261: Physical Therapy Service CDPH 262: Speech Pathology and/or Audiology Service CDPH 255: Social Work Service All the forms required for SNF services can also be requested for ICF in addition to the documents requested below: CDPH 609: Special Treatment Program Service