Cover Letter

Letter on company letterhead with the following information:

• Facility name and address
• Facility ID number (if known)
• Brief description of request
• Include service(s) adding or removing
• 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/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 
  

A.10 – Certificate of Occupancy

[24 CCR section Part 2 section III]

[Title 42 Code of Federal Regulations (CFR) section 416.44]

If construction occurred and if the construction resulted in a new building or addition:

• Submit a Certificate of Occupancy