Cover Letter

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 email 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.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
  

A.10 – California Department of Health Care Access and Information (HCAI) and/or Certificate of Occupancy [22 CCR sections 79583, 79819 and 79821]

Contact HCAI or the local building authority for Title 24 clearance.

If the facility is a newly constructed or remodeled building, submit the following:

• Submit a HCAI Certificate of Occupancy or Construction Final
  

Fire Safety Inspection Request

[22 CCR sections 79583 and 79525]

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