Skilled Nursing Facility and Intermediate 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 or document will delay processing or lead to denial.
Checklist and Instructions
Please submit your documents in this order.
Required Documents to Change Property Owner
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Forms and Supporting Documents
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Additional Instructions
(Each form listed also has instructions on the form)
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Cover Letter
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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
- 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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HS 200 (PDF, 1.5MB)
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Licensure & Certification Application
[Title 22 of the California Code of Regulations (CCR) section 72211(a)]
Tip:
- Page 6, section B, item 6 — 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.
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Supporting Documents
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D.1 - Control of Property
SNF and ICF: California Health and Safety Code (HSC) section 1265(h)
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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