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Form Dhcs 5112 - California Initial Certification Application - Health And Human Services Agency Page 10

STATE OF CALIFORNIA--HEALTH AND HUMAN SERVICES AGENCY

Department of Health Care Services

Licensing and Certification Branch, MS 2600

PO Box 997413

Sacramento, CA 95899-7413

INITIAL CERTIFICATION APPLICATION

FOR ALCOHOL AND/OR OTHER DRUG PROGRAM CERTIFICATION

EXPLANATION OF SECTION A

Supportive documents and forms to be submitted to DHCS.

Initial Certification Application (DHCS 5112).

EXPLANATION OF SECTION B

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Supportive documents and forms to be submitted to DHCS.

Annual Line-item Budget – A line-item budget (projection of revenues and expenditures) for the current

fiscal year that correlates with quarterly and annual written operation reports and, if the provider is a

nonprofit corporation, is approved by the board of directors. [Standards Section 3035 a. 1.]

Program Mission and Philosophy Statement(s) – A written statement(s) describing the program’s

mission and/or philosophy. [Standards Section 3035 a.2.]

Program Description – A written document that describes the program’s alcohol and/or other drug

services and settings that are offered according to the severity of alcohol and/or other drug involvement

and the program's approach to recovery or treatment which shall include but not be limited to an alcohol

and drug free environment. [Standards Section 3035 a. 3.]

A Statement of Program Objectives – Written, time-limited and measurable process and outcome

objectives that can be verified in terms of time and results and that serve as indicators of program

effectiveness. [Standards Section 3035 a. 4.]

Program Evaluation Plan – A written evaluation plan for management decision making. [Standards

Section 3035 a. 5.]

Continuous Quality Management Plan – Written policies and procedures for continuous quality

management which shall include continuity of activities, participant file review, and recovery or treatment

plan review. [Standards Section 3035 a. 6.]

An Outline of Activities and Services to be Provided by the Program – Show outline (A-6 – Weekly

Activity Schedule) for specific activities and services such as: detoxification (if applicable), group and

individual sessions, recovery or treatment planning, continuing recovery or treatment planning recreation,

self-help activities (AA, NA, CA), and other activities/services. [Standards Section 3035 a. 7.]

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Statement of the Admission, Readmission, and Intake Criteria (including detoxification services,

if applicable) – Written admission, readmission, and intake criteria for determining the participant’s

eligibility and suitability for services and procedures. [Standards Section 3035 a. 8.]

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DHCS 5112 (07/13)

Form Dhcs 5112 - California Initial Certification Application - Health And Human Services Agency Page 10