Intermediate Care Facility 
Change of Certification Application Packet-Continuous Nursing​

A State license is required to operate as an Intermediate Care Facilities for the Developmentally Disabled (ICF/DD) in California. An Intermediate Care Facility/Developmentally Disabled (ICF/DD) means “a facility that provides 24-hour personal care, habilitation, developmental, and supportive health services to persons with developmental disabilities whose primary need is for developmental services and who have a recurring but intermittent need for skilled nursing services” pursuant to Health and Safety Code (HSC) section 1250(g). An ICF/DD also means “a health facility which provides care and support services to developmentally disabled clients whose primary need is for developmental services and who have a recurring but intermittent need for skilled nursing services", pursuant to Title 22 of the California Code of Regulations (CCR) section 76079. ​​​

To apply for Medi-Cal certification for a licensed healthcare facility, you must complete the required application packet.​

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 provider instructions are a resource to guide you through the process. 

Please refer to the following links to get started:

• Provider Instructions​
  
• Provider Checklist​​
  

Applicatio​​​​n Packet Forms

• CMS 3070G - ICF for Persons with Mental Retardation Survey​ (PDF)
  
• DHCS 9098 - Medi-Cal Provider Agreement​​​​ (PDF)
  
• HS 200 - Licensure and Certification Application (PDF, 1.5MB)
• ​HS 328 - Notice - Effective Date of Provider Agreement (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​​