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
• 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.cal​hospitalprepare.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

Department of Health Care Access and Information (HCAI) Approval Document of the Completed Construction (Certificate of Occupancy, Certificate of Substantial Compliance or Construction Final) SNF and ICF: HSC sections 1276

SNF: 22 CCR sections 72205, 72601, and 72603

ICF: 22 CCR sections 73213, 73601, and 73605

If this is a newly constructed and/or remodeled building, or if this is not a previously licensed facility (i.e., existing building with no construction or remodeling required) applicant needs to contact the California Department of Health Care Access and Information (HCAI) at the following website for Title 24 clearance: HCAI

Note: HCAI Approval is required for portable bedside hemodialysis

Fire Safety Inspection Request

SNF: 22 CCR sections 72205

ICF: 22 CCR sections 73213

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 OSHPD Fire Life & Safety (FLS) Inspection approval does not replace this form.

SNF: 22 CCR sections 72401 and 72211

ICF: 22 CCR section 73445

Include the forms corresponding with the type of service SNF is requesting to add to the license

• CDPH 242: Chronic Dialysis Service
• CDPH 246: Application for Outpatient Service
• CDPH 259: Rehabilitation (ICF ONLY)
• CDPH 260: Occupational Therapy Service
• CDPH 261: Physical Therapy Service
• CDPH 262: Speech Pathology and/or Audiology Service
• CDPH 255: Social Work Service

• ​CDPH 609: Special Treatment Program Service​