Congregate Living Health Facility and Pediatric Day Health and Respite Care Facility
Report of Change Application Checklist for Change of Property Owner
The following is a list of forms and supporting documents required for a complete application packet. Failure to include every form and document will delay processing or lead to denial.
Checklist and Instructions - Pālease submit your documents in this order and save a copy of all submitted documents for your records.
Required Documents to Change Property Owner
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Forms and Supporting Documentsā
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āāAdditional Instructions
(Each formā listed also has instructions on the form)ā
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āCover Letter
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Cover Letterā
Letter on company letterhead with the following information:
- 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)
- Facility Contact (public phone number, public fax number, public email address, and public webpage). The Facility Contact (Public Use) information is used to store facility contact information for the public.
- 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
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āHS 2ā00 (PDF, 1.5MB)ā
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Licensure & Certification Application
CLHF
and
PDHRC:
Health
and
Safety
Code
(HSC)
sections 1267.13(n) and 1760.4(c)
Title 22
California
Code
of
Regulations
(CCR)
72211(a)
Tip
-
Page 6, section B, item 6 ā An organization will have its own Federal tax ID number
Signature must be from the applicant (Licensee/owner), not the Administrator, unless the owner is the Administrator.ā
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āSupporting Documents
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D.1 - Control of Property
CLHF
and
PDHRC: HSC sections 1267.13(n) and 1760.4(c) and 22 CCR 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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Note: Save a copy of all submitted documents for your records.