Cover Letter​

Letter on company letterhead with the following information:

• License number
• Facility name and address
• Facility ID number (if known)
• Brief description​ of request
• Previous and proposed/new location
• Contact information (name, title, phone number, and e- mail 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/post/california-health-alert-network-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

CHLF: [HSC section 1250(i) and 1267.16(c)]

For a CLHF with more than six beds for persons who are terminally ill and for persons who are catastrophically and severely disabled:

• Submit a Conditional Use Permit
• The Conditional Use Permit must meet the requirements of the City or County in which it is located unless those requirements are waived by the City or County 

Note: for PDHRCs a conditional use permit is not needed

​D.1 - Control of Property

CLHF and PDHRC: [HSC sections 1267.13 (n) and 1760.4 (c)] [22 CCR section 72211(a)]

Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee.

Fire Safety Inspection Request (not applicable for a CHOW unless there is construction)

[22 CCR section 72505 and HSC section 1267.13(a)(b)]

PDHRC Only: HSC section 1761.2

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.