Follow the steps to complete your application efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the request for approval section. Indicate whether this application is for initial program plan approval, conversion from a CCF level facility, change of ownership, or establishing a new facility.
3. Select the appropriate license category by indicating whether the application pertains to ICF/DD-H Program Plan, ICF/DD-N Program Plan, or ICF/DD Program Plan for annual approval.
4. Enter the facility name, telephone number, and Medi-Cal provider ID, if assigned. Make sure to accurately provide the contact information to ensure clear communication.
5. Fill in the facility address, as well as the licensee or corporation details including telephone, fax, and email. Ensure all information is correct and current.
6. Identify the corporate designee and provide their mailing address for follow-up correspondence.
7. Specify the proposed or actual capacity of your facility, including the licensed capacity and the age range of individuals served. Indicate the ambulatory status.
8. Enter the information regarding the Qualified Intellectual Disability Professional (QIDP), including the status (AMBER/NON-AMB).
9. Ensure the licensee or corporate designee signs and dates the application. The signature confirms the accuracy of the information provided.
10. Submit the application to the Department of Developmental Services Community Living Section, using the provided mailing address. You may also save changes, download, or print the completed application as needed.

Complete your application online for a streamlined process.