Intermediate Care Facilities for the Developmentally Disabled-Habilitative
Change of Ownership Application Packet

A State license is required to operate as an Intermediate Care Facilities for the Developmentally Disabled-Habilitative (ICF/DD-H) facility in California. An ICF/DD-H means “a facility with a capacity of 4 to 15 beds that provides 24-hour personal care, habilitation, developmental, and supportive health services to 15 or fewer persons with developmental disabilities who have intermittent recurring needs for nursing services, but have been certified by a physician and surgeon as not requiring availability of continuous skilled nursing care,” pursuant to Health and Safety Code (HSC) section 1250(e).

To report a Change of Ownership, you must complete the required application packet. Refer to Title 22 California Code of Regulations (CCR) sections 76800 through 76962 for information regarding licensure requirements.

How to Apply

An applicant must submit a completed application packet to the Centralized Applications Branch (CAB). The application packet contains the required forms in one location. The provider checklist identifies the required forms and supporting documents needed to apply for licensing and certification. The provider instructions are a resource to guide you through the process. 

Please refer to the following links to get started:

• Provider Instructions (PDF)
• Provider Checklist 
  

Applicatio​​n Packet Forms

• ​HS 200 - Licensure and Certification Application (PDF, 1.5MB)
• HS 215A - Applicant Individual Information (PDF)​
• ​​HS 309 - Administrative Organization and Organizational Structure (PDF)
• CDPH 322 - Transmittal Application for Criminal Background Investigation​ (PDF)
• CDPH 325 - Criminal Record Clearance Submissions (PDF)
• ​HS 400 - Affidavit Regarding Patient Money (PDF)
• HS 402​ - ​Surety Bond Verification (PDF)​​
  
• HS 602 - Transfer Agreement (PDF)
  
• DHCS 1051 - Civil Rights Compliance Review (PDF)
  
• STD 850 - Fire Safety Inspection Reques​t (PDF)
  
• HS 328 - Notice - Effective Date of Provider Agreement (PDF)
  
• DHCS 9098 - Medi-Cal Provider Agreement (PDF)
  
• CMS 3070G - Intermediate Care Facility for Persons with Mental Retardation Survey Report​ (PDF)​
  

Where to Submit Applications

Submit completed application packets to the CAB at the address listed below. Do not send any completed application packets, forms, or supporting documents to the local CDPH, District Office.

          California Department of Public Health
          Licensing and Certification Program
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377