Form Dhcs 5104 - California Department Of Health Care Services -


State of California—Health and Human Services Agency
Department of Health Care Services
Dear Applicant:
As part of the State alcohol and drug certification process, a fire clearance is required from local
authorities for the address at which substance abuse services are to be provided.
The Substance Use Disorder Compliance Division (SUDCD) of the Department of Health Care
Services (DHCS) has been made aware that it is often difficult for a provider to obtain a fire clearance
due to a lack of understanding by local authorities regarding what information will satisfy these
requirements and what form the approval should take (letter, form, etc.).
In an effort to assist providers in clarifying the requirements for local authorities, and perhaps
provide a sample form on which local authorities can notify SUDCD that approval has been
obtained, SUDCD is enclosing a sample format of a fire clearance which you may provide to your
local fire authority. Also enclosed is a transmittal letter which explains to your local fire authority
what forms of notification are acceptable to SUDCD.
Please feel free to take or mail the fire clearance, and the transmittal letters to your local authority
when you request the clearance.
The Department of Health Care Services hopes that this form will expedite your inspection/approval
process. If you have any suggestions for improvements to the forms or have any questions, you
may contact SUDCD at (916) 322-2911.
Substance Use Disorder (SUD) Compliance Division
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
Phone: (916) 322-2911
Fax (916) 322-2658


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