HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Contact Us

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

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

Online Application PDF Form

General Acute Care Hospital and Acute Psychiatric Beds

Copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee (Only required when adding beds in previously unlicensed space)
Department of Health Care Access and Information (HCAI) Certificate of Occupancy (CO), Construction Final (CF), or Substantial Completion (SC)
STD 850 (PDF) form - Fire Safety Inspection Request or a document that contains the fire inspector’s contact information (name, email, and address)
Floor plan that includes a schematic of the room(s)

Bed Suspension

Swing Beds

Documentation/letter approval from Centers for Medicare & Medicaid Services (CMS) approving the requested number of swing beds

Distinct Part Skilled Nursing Facility (D/P SNF) Beds*

Copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee (Only required when adding beds in previously unlicensed space)
Department of Health Care Access and Information (HCAI) Certificate of Occupancy (CO), Construction Final (CF), or Substantial Completion (SC)
STD 850 (PDF) form - Fire Safety Inspection Request or a document that contains the fire inspector’s contact information (name, email, and address)
Floor plan that includes a schematic of the room(s)
HS 400 (PDF) form – Affidavit Regarding Patient Money
HS 402 (PDF) form – Surety Bond Verification
HS 602 (PDF) form – Transfer Agreement (if not co-located to hospital)

D/P SNF Beds - Medicare Certification Documents (Only applicable for Medicare Certification)

CMS 1561 (PDF) form - Health Insurance Benefit Agreement
CMS 671 (PDF) form – Long-Term Care Facility Application for Medicare and Medicaid
HS 328 (PDF) form - Notice-Effective Date of Provider Agreement
HHS 690 (PDF) form - Assurance of Compliance (Submit a verification from the Office of Civil Rights displaying submission of this form)

D/P SNF Beds - Medi-Cal Certification Documents (Only applicable for Medi-Cal Certification)

DHCS 9098 (PDF) form – Medi-Cal Provider Agreement
DHCS 6207 (PDF) form – Medi-Cal Disclosure Statement (Only submit Section V – Subcontractor Information and Significant Business Transactions)
One of the following Internal Revenue Service tax documents:

Helpful Tips

For distinct part (D/P) facilities, submit the application under the main facility and specify the request is for a D/P facility.

If the D/P Director of Nursing is different from the hospital, then submit a Director of Nursing (DON) application.
If the D/P requests to provide supplemental services, change of services (CHOS) application.

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