Intermediate Care Facility/Developmentally Disabled-Nursing
ICF/DD-Continuous Nursingāā
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 for a Change of Location
Forms and Supporting Documentsā
| āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
|
āCover Letter
| Cover Letter Letter on comāpany letterhead with the following information:
- License number
- Facility name and address
- Facility ID number (if known)
- Brief description 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.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)
- āSignatureā
|
āHS 200 (PDF)
| Licensure & Certification Application
Tip:ā - āPage 6, section B, item 6 ā An organization will have its own Federal tax ID number
|
āSupporting Documents
| āA.10 - Construction
Submit one of the following: - Evidence of compliance with local building code requirements or
- Certificate of Occupancy issued by the local building authority
|
āSupporting Documents
| āD.1 - Control of Property Submit a copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee.
|
HS 602ā (PDF)
| Transfer Agreement Copy of current written transfer agreement with a hospital or health facility that meets the requirements of the CCR.
Tip: - The facility administrator may sign this form
|
STD 850āā (PDF)ā
| Fire Safety Inspection Request (not applicable for a CHOW unless there is construction) The STD 850 form must be subāmitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The OSHPD Fire Life & Safety (FLS) Inspection approval does not replace this form
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