Skilled Nursing Facility
Change of Name Application Packet

A State license is required to operate as a Skilled Nursing Facility (SNF) in California. A SNF is “a health facility that provides skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis,” pursuant to Health and Safety Code (HSC) section 1250(c). A SNF also means “a health facility or a distinct part of a hospital which provides continuous skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. It provides 24-hour inpatient care and, as a minimum, includes physician, skilled nursing, dietary, pharmaceutical services and an activity program,” pursuant to Title 22 of the California Code of Regulations (CCR) section 72103.

To report a Change of Name, you must compete the required application packet. Refer to 22 CCR sections 72001 through 72713 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)​​​
  
• DHCS 9098 - Medi-Cal Provider Agreement​​​​ (PDF)
  

• CMS 855A - Medicare General Enrollment Health Care Provider/ Supplier Application​​ (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