Referral Agency
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
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Forms and Supporting Documentsā
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āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
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āCover Letterā
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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
- 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)
- Signature
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āHS 200 (PDF)
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Licensure & Certification Application
[Health and Safety Code (HSC) 1404.5(c)] and [Title 22 California Code of Regulations (CCR) section 74103(a)(3)]
Tip
- Page 6, section B, item 6 ā An organization will have its own Federal tax ID number
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āSupporting Documents
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āD.1 - Control of Property
[HSC 1405(g)] and [22 CCR section 74105(a)(7)]ā
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. āā
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