Ds1852 2026

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The document is an application form from the California Department of Developmental Services for the approval of health facility program plans, including initial approvals, changes in ownership, and annual approvals for various types of facilities. It requires detailed information about the facility, licensee, QIDP (Qualified Intellectual Disability Professional), and administrator, along with contact details and capacity specifications.

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Click ‘Get Form’ to open the ds1852 in the editor.
Begin by filling out the 'Request for Approval' section. Indicate whether you are seeking initial program plan approval, conversion from a CCF level facility, change of ownership, or new facility status.
In the 'License Category' section, select the appropriate program plan type: ICF/DD-H, ICF/DD-N, or ICF/DD for annual approval.
Enter your facility name and contact details including telephone, fax, and email. Ensure that you provide your Medi-Cal Provider ID if assigned.
Complete the 'Facility Address' and 'Licensee/Corporation' sections with accurate information about your organization.
Fill in the proposed/actual capacity and age range of residents. Specify ambulatory status as needed.
Finally, sign and date the application in the 'Administrator' section before submitting it to the Department of Developmental Services.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (121 Votes)

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Ds1852 2026

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