PLEASE COMPLETE THIS FORM FULLY INCOMPLETE APPLICATIONS WILL BE RETURNED - cdph ca 2025

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering the 'Legal Name of Firm' in the designated field. Ensure that this is the full name of your business.
  3. If applicable, provide any 'Doing Business As' (DBA) names in the next field. If you have multiple DBAs, list them on a separate sheet.
  4. Fill out the 'Facility Address' section with complete details including street number, city, state, and ZIP code.
  5. Continue with the 'Mailing Address' if it differs from your facility address. This ensures all correspondence reaches you.
  6. Complete sections for contact information such as 'Facility Telephone Number', 'E-mail Address', and '24-Hour Emergency Telephone Number'.
  7. Indicate your type of ownership by checking the appropriate box and provide details about owners or officers if necessary.
  8. Finally, review all entries for accuracy before signing at the bottom of the form. An incomplete application will be returned.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.
Contact us
How to File a Complaint. Complete the complaint form or draft your own and submit via email NHAP@cdph.ca.gov or Fax Number: (916) 636-6108. Please provide the facility name and address, if applicable.
If the complaint is deemed legally sufficient, the DOH will notify you in writing and provide details of the allegations. This notification may also include a request for a written response.
CDPH documents every complaint received in an electronic tracking system and assigns it to a health facilities evaluator supervisor, a registered nurse who classifies the allegation. Complaint categories range from resident/patient abuse and quality of care/treatment to dietary services and resident/patient rights.
For assistance in resolving a problem with a state agency, we suggest that you contact the director of the state agency, your elected representatives in the California Legislature, or a private attorney.
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