Letter on company letterhead with the following information:

• License number
• Facility name and address
• Facility ID number (if known)
• Brief description of request
• Contact information (name, title, phone number, and email address)
• Emergency Contact Information (name, email, alternate email, phone, fax, 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)
• Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address)
• Signature
  

A.10 – California Department of Health Care Access and Information (HCAI) and/or Certificate of Occupancy

HCAI and Local Building Authority
One of the two documents are required:

For a newly licensed, constructed, or remodeled building, the following is required:

• Title 24 compliance (OSHPD 3 Standards) - a California licensed architect or the local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements:
   
• California Building Code (CBC)
• California Fire Code (CFC)
• California Electrical Code (CEC)
• California Mechanical Code (CMC)
• California Plumbing Code (CPC)
• California Administrative Code (CAC) 

• Certificate of Occupancy 

[HSC section1212 (a)(9)]

Submit a floor plan showing the dimensions of each room and the station placement within each room