Intermediate Care Facility 
Change of Location Application Packet

A State license is required to operate as an Intermediate Care Facility (ICF) in California. An ICF is “a health facility that provides inpatient care to ambulatory or nonambulatory patients who have recurring need for skilled nursing supervision and need supportive care, but who do not require availability of continuous skilled nursing care,” pursuant to Health and Safety Code section 1250(d). An ICF also means “a health facility, or a distinct part of a hospital or skilled nursing facility, which provides the following basic services: Inpatient care to patients who have need for skilled nursing supervision and need supportive care, but who do not require continuous nursing care,” pursuant to Title 22 of the California Code of Regulations (CCR) section 73051.

To report a Change of Location, you must complete the required application packet. Refer to 22 CCR sections 73001 through 73727 for information regarding licensure requirements.

How to Apply

An applicant must submit a completed application packet to the Centralized Applications Branch (CAB). The application packet contains the required forms in one location. The provider checklist identifies the required forms and supporting documents needed to apply for licensing and certification. The prov​ider instructions are a resource to guide you through the process. 

Please refer to the following links to get started:

• Provider Instructions (PDF)
• Provider Checklist 
  

Applicatio​​​​n Packet Forms

• ​HS 200 - Licensure and Certification Application (PDF, 1.5MB)​​
  
• STD 850 - Fire Safety Inspection Reques​t (PDF)
  
• DHCS 9098 - Medi-Cal Provider Agreement​​​​ (PDF)
  

• CMS 855A - Medicare General Enrollment Health Care Provider/ Supplier Application​​ (PDF)​​​​
  

Where to Submit Applications

Submit completed application packets to the CAB at the address listed below. Do not send any completed application packets, forms, or supporting documents to the local CDPH, District Office.

          California Department of Public Health
          Licensing and Certification Program
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377