Administrative Frequently Asked Questions

Administrative 2022 California Administrative Code (CAC)

All code sections cited are based on the 2022 California Administrative Code (CAC), unless otherwise noted.

1. Does HCAI provide a list of governing codes that pertain to health facilities?

Yes. Current and previous governing codes are listed in Code Application Notice (CAN) 1-0.

2. If a project is submitted under the applicable governing codes but a newer edition of a code is available, can we pick and choose portions of a code?

No. The project must comply with all governing codes in effect when a Preliminary or Final Application for Plan Review is submitted to the Office. Please refer to CAN 1-0.

3. What HCAI procedure should be used when an architect or engineer disagrees with an HCAI plan review staff member or an HCAI field staff member on a code interpretation?

HCAI′s clients should use the Comment and Process Review (CPR) procedure to resolve disagreements involving code interpretation issues or HCAI processes and procedures. Clients can also use the e-Service Portal (eSP). For instruction see OSHPD eSP User Guide, Appeals Using the Comment and Process Review.

4. What is required of a Skilled Nursing Facility (SNF) for the temporary voluntary conversion of all or a portion of its licensed bed capacity for the purpose of using the facility as a licensed Mental Health Rehabilitation Center (MHRC)?

In 2004, legislation was passed that explains the requirements. Please refer to Section 1271.15 of the Health and Safety Code.

5. Are any construction projects for hospitals and skilled nursing facilities exempt from the HCAI plan review process?

Legislation has been passed which provides that, under specific circumstances, a hospital or skilled nursing facility project may be exempt from the HCAI plan review process. The enactment of Assembly Bill 2632 (Chapter 453, Statutes of 2004) added Health and Safety Code Section 129875.1 which allows certain maintenance and repair work projects for hospitals and skilled nursing facilities to be exempt from plan review, if specific criteria is met. AB 2632 provisions apply to such projects in “single-story” buildings.

The enactment of Senate Bill 1838 (Chapter 693, Statutes of 2006) added Health and Safety Code 129880 which allows hospital, skilled nursing facility and intermediate care facility construction or alteration projects costing less than $50,000 to be exempt from the HCAI plan review process, if specific criteria are met. HCAI′s Policy Intent Notice (PIN) 36 outlines the process and procedures for submittal of such projects.

Although projects that meet the criteria for Health and Safety Code Section 129875.1 or 129880 are exempt from the HCAI plan review process, they are not exempt from issuance of a building permit and construction observation by HCAI.

HCAI′s manual for Field Review (FR) Projects, Excluded (E) from OSHPD Plan Review, and Expedited Review (ER) (FREER Manual) provides a guide to help identify other types of projects that may be considered “excluded”. Projects that are identified as “excluded” will not require submittal of a building permit application, project plans or a fee. The project is not exempt from the HCAI field observation necessary to assure code compliance.

6. Why does the application form for HCAI plan review request the name of a “Facility Representative”?

Upon the recommendation of the hospital industry, HCAI requests that hospitals and skilled nursing facilities identify a “facility representative” who will receive copies of all project correspondence from HCAI and who will be the contact person when discussion of plan review or construction issues is necessary. This provides facilities easier access to information about the review of their projects and reduces confusion regarding the status of the reviews. When projects are received by HCAI, the name of the facility representative, if identified, is entered into the eServices Portal (eSP) database and this information is used for sending all correspondence to that individual. If this information is not provided, the “facility administrator” will receive copies of all correspondence.

7. Can a licensed specialty contractor prepare plans and specifications for a project consisting only of a fire sprinkler system?

see Fire and Life Safety, General, Question 3

8. What are the stamping and signature requirements for a deferred submittal?

Stamping and signature requirements must comply with California Administrative Code (CAC) Section 7-126.

9. Who is responsible for updating the Testing, Inspection, and Observation (TIO) Program for a specific project?

The architect or engineer in responsible charge of the work must maintain the TIO Program, pursuant to CAC Section 7-141 (d).

10. Does HCAI have a special form or letter for submitting an Alternate Method of Compliance (AMC) request?

HCAI prefers that AMC requests are submitted on the Alternate Method of Compliance Form (OSH-FD-126) available from the OSHPD Forms web page.

11. My plans have been stamped “approved” by HCAI. However, during construction the HCAI field staff has stated that the plans are not code compliant and has given verbal direction to make changes that deviate from the approved plans. What recourse, if any, do I have when this occurs?

HCAI has an internal process for resolving issues pertaining to the approved plans. Clients may contact the Regional Compliance Officer (RCO) to verify that the issue is being reviewed and resolved internally. Insofar as practical, the plans will stand as approved. However, issues involving life safety must be corrected or changed as necessary to the extent required to make the building and its occupants safe regardless of what is shown on the approved plans

If the client does not believe the issue has been resolved satisfactorily, they may use the Comment and Process Review (CPR) procedure to resolve disagreements involving code interpretation issues or HCAI processes and procedures.

12. Does HCAI have any concern over the process of Owner approval of Owner Vendor installations so long as they meet the Approved Contract Documents?

Yes. The installation by vendors must be under the general responsibility of the General Contractor of Record or the Owner/Builder for the specific project under which it is being installed, or must be submitted as a separate project. Otherwise, the work is being performed without benefit of a building permit, verification of appropriately licensed contractor, and verification of the necessary Worker′s Compensation coverage.

13. Would HCAI allow the contractor to hire the special inspector?

No. Section 1701A.4 of the California Building Code (CBC) requires the owner to employ the special inspector(s).

14. Are changes to plans required to be incorporated into the original plans?

No. HCAI does not have a policy that changes be incorporated into the original plans.

15. Does a design professional have to stamp/approve a small project if all work done is using pre-approved details?

Yes. The CAC requires plans for hospitals to be prepared by an appropriately California licensed professional. The pre-approved details have been prepared and stamped by a licensed professional. Therefore, these should not require re-stamping. However, someone must determine the applicability of the details to the project and prepare plans showing where the details apply, etc.

16. Can the Inspector of Record (IOR) daily report be electronic or does it have to be a hard copy?

The regulations do not specify whether the IOR report has to be a hard copy. The report is required to be retained on the job site and made available to the HCAI field staff, the architect or engineer in responsible change, or the owner upon request. The original field records must be turned over to the hospital governing authority upon completion of the project. Therefore, the owner may have a preference regarding the manner in which reports are made and maintained.

Regardless of the media or method of reporting used, the IOR must demonstrate, upon request by HCAI field staff that their field records comply with the applicable regulations. If an electronic method is used, the IOR must have a manner in which the data is backed-up in the event of a hard disk crash, loss of computing equipment, etc.

17. There appears to be confusion regarding HCAI′s jurisdiction as it relates to the hospital building site. If the local jurisdiction is responsible for parking, landscaping, drainage, site utilities, etc., how far does HCAI′s jurisdiction extend beyond the building line? It was my understanding that HCAI didn′t look at anything more than 5 feet outside of the building perimeter.

It may be appropriate and necessary for HCAI to review certain work extending beyond 5 feet from the building, such as the underground fire main, private utilities, slopes and grade pertaining to accessibility, proximity of adjacent structures for wall and opening protection requirements, fire department access, etc. Other work shown on drawings beyond the arbitrary 5 ft. dimension are clearly within the responsibility of the local jurisdiction, such as size and number of parking spaces, landscaping and other site development features, etc. The determining factor is whether the work in question affects the compliance of the hospital building with the California Building Standard Code requirements that are enforced by HCAI. Please refer to CAN 2-0.

18. Is it permissible to plot the HCAI approval stamp for office reviews or field reviews on our drawings?

No, this is no longer needed with electronic reviews as the stamp is automatically applied. A space on the title block is required to be provided in the same location on each sheet for the electronic approval stamp.

19. What is the proper procedure for adding additional sheets to an approved set of construction documents?

CAC Section 7-153(a) states, “Work shall be executed in substantial conformance with the construction documents approved by the Office. Changes in the work shall be made by Amended Construction Documents (ACD) approved by the Office.

NOTE: Added scope to a project may constitute a new project. If there is any question, contact the Plan Review Supervisor for clarification prior to submitting the work to HCAI.

20. If Amended Construction Documents are submitted simultaneously or closely following each other, should the information from ACD#1 (now at HCAI but not approved yet) be clouded on ACD#2 (if on the same sheet) or should only the HCAI approved changes be shown?

The clouded changes from ACD#1 should be shown on ACD#2.
Clearly note on AC#2 that those AC#1 changes have not yet been approved.

21. Are wet signatures always required on documents submitted to HCAI?

In CAC Section 7-111, the definition of “SIGN, SIGNED, SIGNATURE, and SIGNATURES” means to affix an individual′s signature by manual, electronic, or mechanical methods. Manual method includes, but is not limited to, a pen and ink signature. Electronic method includes, but is not limited to, scanned signature images embedded in construction documents, faxes, or other electronic document files. Mechanical method includes, but is not limited to, rubber stamp signature.

22. Does the HCAI Anchorage Pre-approval Program approve and list building materials, for example: fire-resistive systems and components?

No. The HCAI Anchorage Pre-approval Program is not a building materials listing program. The program is limited to approvals of anchorage and bracing systems only. HCAI′s acceptance of fire-resistive systems and components is based on Chapter 7 of the CBC. Tested and listed systems are acceptable. CAN 2-703.3 establishes guidelines for the preparation, submittal, and review of Engineering Judgements.

HCAI does not provide endorsements regarding the acceptance of suitability of any manufacture′s product.

23. Are there different requirements for Functional Programs for different types of projects?


  1. Standard Functional Programs are required for all projects in which there is a change in occupancy, function or use of an existing space. This may include the same use of a space, but there are added functions within that space.
  2. For imaging equipment replacement projects, it is required to include a list of proposed procedures that may be performed in this imaging room. As technology for imaging has improved the types of procedures performed has increased in complexity. This has allowed for imaging equipment that was originally design as diagnosis only to now be able to perform more invasive procedures, but the room environment is still that of a diagnostic use. If the procedures to be performed go beyond diagnostic services and are now becoming more treatment oriented, the room’s environment may need to be revised to accommodate those services more safely. The list of procedures is required for California Department of Public Health (CDPH) review to determine if the room environment is appropriate.
  3. For all pharmacy projects that include sterile compounding, it is required that the Sterile Compounding Pharmacies for Hospital Facilities Advisory Guide be completed and submitted with the project’s Functional Program. The Pharmacy Summary Checklist (appendix B of the guide) must also be submitted as a separate file for CDPH review.
24. How can changes be made to the list of professionals on a project?

Refer to California Administrative Code 7-152, Replacement of an architect, engineer, inspector of record, Approved Agency, special inspector or contractor. The documentation required depends on the type of professional license and when the replacement occurs.

  • Contractor
    • Post Plan Approval
      • Revised Project Application (HCAI-OSH-100 or HCAI-OSH-121)
      • Verified Compliance Report for incoming contractor (HCAI-OSH-123)
      • Final Verified Compliance Report for outgoing contractor (HCAI-OSH-123)
      • Worker’s Compensation Insurance Certificate
  • Inspector of Record (IOR)
    • Post Plan Approval
      • Application for Inspector of Record (HCAI-OSH-124)
      • Verified Compliance Report for incoming IOR (HCAI-OSH-123)
      • Final Verified Compliance Report for outgoing IOR (HCAI-OSH-123)
      • IOR Workload Report
      • If there are multiple IORs on the project: Modified Section G, Inspector of Record Responsibility, of the Testing, Inspection, and Observation Form.

Upload the required documents to the eServices Portal using Virtual Folder 80 – Project Documents and notify the support teams at or

Architectural 2022 California Building Code (CBC)

All code sections cited are based on the 2022 California Building Code (CBC), unless otherwise noted.

1. Does HCAI allow the use of modular toilet/sink combination units in health facilities?

Yes, but only in Intensive Care Units. Section 1224.29.1.4 allows the use of modular toilet/sink combination units in Intensive Care Units. The 2022 California Building Code (CBC) states that toilet fixture must be completely contained within cabinetry when not in use and exhaust ventilation requirements must comply with the 2022 California Mechanical Code (CMC).

2. What are the requirements for Electronic Medical Records (EMR) in health care facilities?

Section 1224.21.2 requires that hospitals provide a health record service that contains a work area for sorting and recording either paper or electronic media records and a storage area for either paper or electronic media records. Both the work area and the storage area must be indicated on the construction plans for HCAI review.

Active and inactive medical records may be located off-site if approved by the California Department of Public Health. Medical record availability requirements are found in Section 70751(f) of Title 22, California Code of Regulations which states: “Medical records shall be filed in an easily accessible manner in the hospital or in an approved medical record storage facility off the hospital premises”. The California Department of Public Health, Licensing and Certification (L&C) is authorized to approve the “off-site” storage of medical records, whether the records are active or inactive. For new construction or a relevant remodeling project, HCAI must receive a copy of the L&C approval letter if the electrical medical records system is “off the hospital premises”. If the EMR computer server is located in the hospital, HCAI must review the server location, anchorage, fire and life safety requirements, mechanical requirements, and electrical requirements.

Electrical 2022 California Electrical Code (CEC)

All code sections cited are based on the 2022 California Electrical Code (CEC), unless otherwise noted.

1. When is fire-resistant construction required for an electrical room or a transformer room?

Article 450.21(B) states that individual dry-type transformers of more than 112 ½ kVA installed indoors must be installed in a transformer room of fire-resistant construction. Unless otherwise specified in this article, the term fire-resistant means construction having a minimum fire rating of one hour. Please refer to Article 450.21(B) for exceptions.

2. Are wireless nurse call systems allowed in health facilities?

Wireless nurse call systems are allowed in health facilities. The system must comply with ANSI/UL 1069, Standard for Hospital Signaling and Nurse Call Equipment. In addition, all wireless nurse call systems must comply with Article 517.123 including two-way voice communication requirements for patient stations installed in hospitals.