Cover Letter

Letter on company letterhead with the following information:

• License number
• Licensee physical address
• Facility name and ID number (if known)
• Brief description of request
• Previously and proposed/new location
• 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 
  

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)
  

* CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, is an acceptable form to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by the local building authority or HCAI. 

• Certificate of Occupancy 

Fire Safety Inspection Request

The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form