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.calhospitalprepare.o​rg/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
  

[22 CCR section 78227(1) and 78501(a)(1) and (b)]

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

Proposal to Share Space

[HSC section 1578 and 1578.1]

If your facility will share space according to HSC section 1578 and 157.1, submit a copy of the ADH 0007.

Fire Safety Inspection Request ​

[HSC section 1574.7(b)]

[22 CCR section 78409]

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