āCongregate Living Health Facility and Pediatric Day Health and Respite Care Facility
Report of Change Application Checklist for Change of Bed
The following is a list of application forms and supporting documents required for a complete application packet. Failure to include each of the forms and documents will delay processing.
Checklist and Instructions - Pālease submit your documents in this order
Required Documents to Add/Reactivate/Remove a Bed(s)
āForms and Supporting Documentsā
| āāAdditional Instructions
(āāāEach form listeādā also has instructions on the form)ā
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āCover Letteāār
| Cover Letterāā
Letter on company letterhead with the following information:ā
- 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://wwāw.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
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āHS 200 (PDF)
| Licensure & Certification Application
CLHF and PDHRC: [Title 22 of the California Code of Regulations (CCR) section 72201(b)(2), 72201(b)(6), and 7221(a)] PDHRC: [Health and Safety Code (HSC) section 1267.13(n) and 1760.4(c)]
Tip - Page 6, Section B, item 6 ā An organization will have its own Federal tax ID number.
Note: HS 200 is not required for bed suspension.
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āSupporting Documents
| āA.7 ā Bed Capacity CHLF: [HSC section 1250(i) and 1267.16(c)]
For a CLHF with more than six beds for persons who are terminally ill and for persons who are catastrophically and severely disabled:
- Submit a Conditional Use Permit
- The Conditional Use Permit must meet the requirements of the City or County in which it is located unless those requirements are waived by the City or County
Note: for PDHRCs, a conditional use permit is not needed.
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Supporting Documents
| A.10 - Construction CLHF Only: [HSC section 1267.19] PDHRC Only: [HSC section 1761.8]
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
Note: not required for bed reduction or suspension if no construction occurred
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āSupporting Documents
| āFloor Plan CLHF and PDHRC: [HSC section 1267.13 and 1761.8]
Submit a floor plan that describes the requested change of beds including a schematic of the room(s).
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āSTD 850 (PDF)
| Fire Safety Inspection Request CLHF Only: [22 CCR section 72505] [HSC section 1267.13(a)(b)] PDHRC Only: [HSC section 1761.2]
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 HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form.
Note: an approved STD 850 Fire Safety Inspection Request is not required for bed reduction or suspension if no construction occurredā
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