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​

ICF/DD: 22 CCR section 76213(a)

ICF/DD-H: 22 CCR section 76847(b) and Health and Safety Code (HSC) section 1267.8

Submit one of the following:

• Evidence of compliance with local building code requirements or
• Certificate of Occupancy issued by the local building authority
  

Transfer Agreement

ICF/DD: 22 CCR section 76505(a)

ICF/DD-H: 22 CCR section 76909(a)

Copy of current written transfer agreement with a hospital or health facility that meets the requirements of the CCR.

Tip:

• The facility administrator may sign this form