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 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 Change Property Owner
Forms and Supporting Documentsā
| āāAdditional Instructions
(āāāEach foāārm 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 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://wāww.calhospitalpreparāe.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: Health and Safety Code (HSC) sections 1267.13(n) and 1760.4(c)
Title 22 California Code of Regulations (CCR) 72211(a)
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āSupporting Documents
| 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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