How to start a skilled nursing facility in California

California requires a Skilled nursing facility license from California Department of Public Health, Center for Health Care Quality — Licensing & Certification (Centralized Applications Branch) to operate a skilled nursing facility. Fee: $1,061 per bed (FY 2026-27 schedule), per CDPH's licensing fee table.

License required

Yes

License

Skilled nursing facility license

Issuing agency

California Department of Public Health, Center for Health Care Quality — Licensing & Certification (Centralized Applications Branch)

Fee

$1,061 per bed (FY 2026-27 schedule), per CDPH's licensing fee table.

Renewal

Every year · Annual license fee per bed per the CDPH fee table.

Insurance and bonds

Surety bond required when the licensee manages patient money; the checklist sizes it above the amount handled.

Medicare certification

Separate from the state license. The state survey agency runs an unannounced standard health survey, a Life Safety Code survey and an emergency-preparedness survey against 42 CFR Part 483 Subpart B. For a Medicare SNF the state certifies and the CMS Location decides Medicare participation; for a Medicaid-only NF the state's certification is final and the state Medicaid agency decides participation.

Regulation

Cal. Health & Safety Code §1250 et seq.; 22 CCR Div. 5, Ch. 3 (§72101 et seq.)

1. Assemble the SNF initial application packet from the CDPH checklist
2. Obtain building clearance from HCAI (Title 24) and a fire clearance
3. Submit the packet to CDPH's Centralized Applications Branch; fees are accepted only after an analyst confirms the packet is complete
4. Post a surety bond if the facility will manage patient funds
5. Pass the CDPH licensing survey
6. For Medicare/Medicaid, complete federal certification and Medi-Cal enrollment

Program

Medi-Cal

Enrollment portal

Provider Application and Validation for Enrollment (PAVE)

Fiscal agent

California MMIS Fiscal Intermediary (claims/billing); fee-for-service enrollment itself is done by the DHCS Provider Enrollment Division (PED)

Application fee

DHCS charges $750 for applicable applications submitted in calendar year 2026, paid by EFT inside PAVE (or cashier's check for paper applications). DHCS exempts individual practitioners and physician and non-physician practitioner groups. Federal rule (42 CFR 455.460): the state must collect the CMS application fee from institutional providers that are newly enrolling or re-enrolling; individual physicians and non-physician practitioners are exempt, as are providers already enrolled in (or that already paid the fee to) Medicare or another state's Medicaid/CHIP. CMS set the fee at $750 for calendar year 2026.

Fingerprinting

Federal rule (42 CFR 455.434, 455.450(c)): providers the state places in the 'high' categorical risk level, and anyone owning 5% or more of such a provider, must submit fingerprints for a criminal background check.

Site visit

For managed care network providers that a plan screens itself, DHCS requires the plan to repeat post-enrollment site visits at least every five years for moderate-risk and every three years for high-risk providers (APL 22-013). Federal rule (42 CFR 455.432, 455.450(b)-(c)): the state must do site visits before and after enrollment for providers in the 'moderate' or 'high' risk levels, and any enrolled provider must allow unannounced on-site inspections.

Revalidation

Revalidation requests come through PAVE. In June 2026 DHCS told CMS it would run a risk-based two-year campaign to revalidate high-risk providers early, beyond the federal schedule. Federal rule (42 CFR 455.414): every enrolled provider must be revalidated at least once every 5 years.

Full California Medicaid enrollment guide →

CON program

No

California certificate of need details →

State minimum wage

$16.90 an hour

Effective

2026-01-01

Scheduled increases

Rises to $17.40 on 2027-01-01 (annual CPI adjustment).

Direct-care wage floor

SB 525 health care worker minimum wage covers licensed home health agencies (and skilled nursing facilities owned or controlled by a hospital or integrated system); independent SNFs, residential care and congregate living health facilities are not covered. Rates are tiered by facility type; for the residual 'all other covered health care facilities' tier the minimum is $23.00/hour from 2026-07-01, rising to $25.00 on 2028-07-01.

HCBS 80/20 rule

Federal baseline: 42 CFR 441.302(k) requires the state to show that each provider spends at least 80% of Medicaid payments for homemaker, home health aide and personal care services under 1915(c) waivers on direct care worker pay and benefits. Compliance starts 2030-07-09 (for managed care, the first rating period starting on or after that date); annual payment-adequacy reporting under 441.311(e) starts 2028-07-09. A state may set a lower share for state-defined small providers and exempt providers facing hardship, each only through a public notice-and-comment process. The eCFR text has not changed since 2024-07-09. No state-published 80/20 implementation step (small-provider criteria, hardship exemption or reporting guidance) was found for this state in the official sources reviewed.

Skilled nursing facilities — active organization NPIs (NPPES)

2,929 (as of Sep 13, 2026)

Medicare/Medicaid-certified nursing homes (CMS Care Compare)

1,165 (as of Aug 1, 2026)

Total Medicaid and CHIP enrollment (latest reported month)

11,659,421 (as of Jun 1, 2026)

All California Skilled nursing Medicaid rates, ranked →