Congregate Living Health Facility and Pediatric Day Health and Respite Care Facility
Report of Change Application Checklist for Change of Location
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 Relocate a Facility
Forms and Supporting Documentsā
| āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
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āCover Letter
| Cover Letterā Letter on company letterhead with the following information: - License number
- Facility name and address
- Facility ID number (if known)
- Brief descrāiption of request
- Previous and proposed/new location
- 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.calhoāspitalprepare.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)
- āāSignature
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āāHS 200 (PDF)
| Licensure & Certification Application
CLHF and PDHRC: [Title 22 of the California Code of Regulations (CCR) section 72201(b)(5)] PDHRC Only: [Health and Safety Code (HSC) section 1267.13(n) and 1760.4(c)]
Tipā - āPage 6, section B, item 6 ā An organization will have its own Federal tax ID number
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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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āSupporting Documents
| āA.10 - Construction
CLHF and PDHRC: [HSC section 1267.19] PDHRC: [HSC section 1761.8]
Submit one of the following: - Evidence of compliance with local building code requirements or
- Certificate of Occupancy issued by the local building authority
Note: CLHFs and PDHRCs are not subject to architectural plan review by the Office of Statewide Health Planning and Development.
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āSupporting Documents
| āD.1 - Control of Property CLHF and PDHRC: [HSC sections 1267.13 (n) and 1760.4 (c)] [22 CCR section 72211(a)]
Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee.
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HS 602ā (PDF)
| Transfer Agreement CLHF and PDHRC: [22 CCR section 72519(a)] [HSC sections 1267.13 (n) and 1760.4(c)]
Copy of current written transfer agreement with a hospital that meets the requirements of the California Code of Regulations
Tips - The facility administrator may sign this form
- The facility may not have a provider number yet and this line may be left blank
|
STD 850āā (PDF)ā
| Fire Safety Inspection Request (not applicable for a CHOW unless there is construction) [22 CCR section 72505 and 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.
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Floor Plan
| āFloor Plan
A floor plan is required showing the level of care in each room and per bed.
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