Form Dhcs 5104 - California Department Of Health Care Services

Form Dhcs 5104 - California Department Of Health Care Services -

State of California—Health and Human Services Agency

Department of Health Care Services

TOBY DOUGLAS

EDMUND G. BROWN JR.

DIRECTOR

GOVERNOR

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

Form Dhcs 5104 - California Department Of Health Care Services -