The Department of Public Health, Licensing and Certification (L&C) Program, is notifying specific health facilities noted above, that L&C’s new website is available to obtain Initial or Change of Ownership (CHOW) licensure/certification application forms for the following facility types: 
              1.      Skilled Nursing Facilities (SNF) 
              2.      Nursing Facilities (NF) 
              3.      Intermediate Care Facilities (ICF) 
              4.      Intermediate Care Facilities for the Developmentally Disabled (ICF/DD) 
              5.      Intermediate Care Facilities for the Developmentally Disabled – Habilitative (ICF/DD-H) 
              6.      Intermediate Care Facilities for the Developmentally Disabled – Nursing (ICF/DD-N) 
              7.      Primary Care Clinic/Rural Health Clinic (PCC/RHC) 
              8.      Home Health Agencies (HHA) 
              9.      Chronic Dialysis Clinics [End Stage Renal Disease (ESRD)]

L&C’s health facilities forms website address is:

www.cdph.ca.gov/pubsforms/forms/Pages/LicensingandCert.aspx

For each SNF, NF, ICF, ICF/DD, ICF/DD-H, ICF/DD-N and PCC/RHC, HHA and ESRD category, the website includes the fee required, a facility application request letter and instructional checklist to assist you in preparing your application package and the required forms. The forms cannot be saved when the data has been typed in the form. Print completed form and make a copy of each form for your files. Once you have completed all the required forms, submit the required fee, forms and any attachments to L&C’s Centralized Application Unit (CAU). CAU’s address is noted on each health facility’s application request letter. In addition to the website, licensing/certification applicants may contact CAU at (916) 552-8632 or e-mail us at CAU@cdph.ca.gov regarding any questions or assistance in filling out the forms.

We are pleased to announce that CAU developed a new form, CDPH 414 (8/08), Application for Health Facility Change of Location. This form can be found at our new website listed above under L&C forms. Mail the completed form and any attachments to the appropriate district office for processing for any change of location information.

If you have any questions concerning this letter, contact Elena Marquez, Acting Chief of CAU, at (916) 552-8756.

Sincerely,

Original Signed by Kathleen Billingsley, R.N.

Kathleen Billingsley, R.N.
Deputy Director