HEALTH CARE FACILITY LICENSING AND CERTIFICATION

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Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

For application status requests, please include the following in your email:

Name of Facility or Agency
License or Facility/Agency # (if applicable)
Address
Facility or Provider Type
Date Documentation Sent
Contact Number

Congregate Living Health Facility and Pediatric Day Health and Respite Care Facility

Report of Change Application Checklist for Change of Service

The following is a list of application forms and supporting documents required for a complete application packet. Failure to include each of the forms and documents will delay processing.

Checklist and Instructions - Please submit your documents in this order

Required Documents to Add or Remove a Service

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
Cover Letter	Cover Letter PDHRC: [Health and Safety Code (HSC) section 1763.4] Letter on company letterhead with the following information: License number Facility name and address Facility ID number (if known) Brief description of request: Indicate the type of service you would like to add or remove. If adding the Transitional Health Care Needs Optional Service Unit, please specify your request for this service here 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 Note: For PDHRCs who opt to provide services to individuals 22 years of age and older, the PDHRC must apply and be approved to operate a Transitional Health Care Needs Optional Service Unit by requesting this service as listed above.
HS 200 (PDF, 1.5MB)	Licensure & Certification Application CLHF and PDHRC: [Title 22 of the California Code of Regulations (CCR) section 72201(b)] CLHF: [HSC section 1267.13(n)] PDHRC: [HSC section 1760.4(c)] Tip Page 6, section B, item 6 — An organization will have its own Federal tax ID number
Supporting Documents	A.3 – Type of Change CLHF and PDHRC: [HSC section 1250(i)(2)(A), (B) and (C)] Under Subsection (n.), specify which of the following services the applicant will be providing: CLHF A: Services for individuals, who are mentally alert, physically disabled individuals who may be ventilator dependent CLHF B: Services for individuals who have a diagnosis of terminal illness, a diagnosis of a life-threatening illness; or both CLHF C: Services for individuals who are catastrophically and severely disabled. Services offered to a catastrophically disabled person shall include, but not be limited to speech, physical, and occupational therapy
Supporting Documents	A.10 - Construction CLHF: [HSC section 1267.19] PDHRC: [HSC section 1761.8] If construction occurred or if a newly constructed building: Submit evidence of compliance with local building code requirements or; Certificate of Occupancy issued by the local building authority
STD 850 (PDF)	Fire Safety Inspection Request CLHF and PDHRC: [22 CCR section 72505] CLHF: [HSC section 1267.13(a)(b)] PDHRC: [HSC section 1761.2] If there is any construction, 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.

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