Health Facility Program Plan (HFPP) Application form is used for processing transactions involving the operations of Intermediate Care Facilities (ICF) for the Developmentally Disabled (ICF/DD), Habilitative (ICF/DD-H), Nursing (ICF/DD-N) and Developmentally Disabled-Continuous Nursing Care (DD-CNC) waiver program.
DDS uses the Health Facility Program Plan Application form (DS 1852) as a control document for the initial program plan review, Qualified Intellectual Disabilities Professional (QIDP) approvals, and notification of changes to your approved program plan.
For an initial Program Plan approval, you will receive an approval letter and a signed copy of the DS 1852. Any QIDP changes made after the initial program plan approval need to be reviewed and approved by the Community Living Section (CLS) staff. Submit a copy of the QIDP applicant’s degree, license, or qualifying document and a copy of their resume along with the application completed front and back.
You will receive a decision on the requested action via a signed copy of your Application form DS 1852. If the assigned analyst has any questions you will be contacted by phone, email, or fax.
The California Code of Regulations, Title 22 Section 76857 states: “Any changes in the facility operation which alter the contents of the approved program plan, including changes of approved staff, shall be reported to the Department of Developmental Services within 10 working days.” Notifications of any changes to the program plan by a provider (other than the QIDP approval outlined above) should be provided to the Department in writing via mail, email, or fax (see contact information below). The department does not provide letters of approval for these changes. If the Department has questions about your changes, the assigned analyst will contact you by phone, email, or fax.
For changes to the facility ID Team Consultant staff other than the QIDP, it is the responsibility of the facility to obtain and maintain the current license or other qualifying document, resume and contract. A DS 1852 form is not required for direct care staff (DCS changes).
DDS keeps a database of all ICF/IID type facilities. We request your assistance to ensure that we have up to date information on file. Please use the DS 1852 form to keep DDS updated with changes in addresses, email and phone numbers.
With your request for approval or notification of change, please submit any supportive documents with the HFPP Application indicating the type of change to:California Department of Developmental Services
Community Living Section
1215 O Street (MS 8-30)
Sacramento, CA 95814 916-654-1965 or e-mail: firstname.lastname@example.org.
The application, along with the supportive documents, will facilitate and expedite the processing of your request/notification while providing an official record of your transaction. If you have any questions regarding this process, contact the Community Living Section at 916-654-1965 or send an e-mail to email@example.com.
Last modified: July 1, 2021