Health Facilities CDPH 327Complete Package with Attachments-California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities CDPH 327 ChineseComplete Package with Attachments-California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities CDPH 327 KoreanComplete Package with Attachments-California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities CDPH 327 SpanishComplete Package with Attachments-California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities CDPH 327 VietnameseComplete Package with Attachments-California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities CDPH 327 Braille File FormatComplete Package with Attachments-California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities CDPH 414 Application for Health Facility Change of Location (PDF) On-Time Quality Improvement Project L&C Forms CDPH 930Request for Adult Day Health Care (ADHC) Center Moratorium Exemption (PDF) L&C All Forms PageA listing of forms, application letters, and checklists used by L&C (PDF) Miscellaneous Forms ADH 0006Staffing/Services Arrangement (PDF) ADH 0008Request for Designation as a Rural Alternative Adult Day Health Care (ADHC) Center (PDF) ADH 0014Adult Day Health Care Program Flexibility Request (PDF) CDA 278Administrator and Program Director Information (PDF) CDA 282Local Fire Inspection authority Information (PDF) DHCS 1051Civil Rights Compliance Review (Title VI, Section 504, ADA) (PDF) DHCS 9098Instructions for Completion of the Medi-Cal Provider Agreement IMS 32Assurance of Compliance With the Department of Health, Education, and Welfare Regulation Under Title VI of the Civil Rights Act of 1964 (PDF) IMS 33Licensee Balance Sheet (PDF) IMS 35Cash Flow Forecast (PDF) IMS 36Medi-Cal Participation Agreement (PDF) MC 406Disclaimer of Conflict of Interest (PDF) |