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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

CERTIFICATION APPLICATION INSTRUCTIONS

This application package contains the materials necessary to apply for a certification of an alcohol and/or other

drug program with the Department of Health Care Services (DHCS).

It is vital that you carefully read each component within this application in addition to the following documents

which can be located on the website

before beginning to fill out the application.

1. Alcohol and/or Other Drug Program Certification Standards.

( Other Drug Program Certification

and

Standards.doc),

2. Data Collection Requirements for any program licensed or certified by DHCS that receives at least one dollar

($1.00) of public alcohol or other drug treatment funding.

( ) .

Please read each required application package form carefully and provide all requested supplemental documents.

DO NOT LEAVE ANY ITEMS BLANK. NOTE: If a question does not apply, please respond with “Not Applicable”

or “N.A.”. Do not make changes to these forms.

USE “BLUE” INK TO SIGN ALL FORMS.

Do not use white

out/correction fluid to make corrections. To correct an error, place a single line through the entry and enter the

correct information. The individual responsible for making the correction must initial and date the correction. You

should retain a photocopy of the completed documents for your files. We may need to contact you in the future

and we will be referring to the information in the documents you provided.

If, after you have totally read the entire application package, you determine that you would like technical

assistance or training addressing certain elements of the application process, you may request assistance without

charge to you from the Department’s consulting agency. The request may be made online at

You may also contact the agency via mail, phone, or fax. The single

statewide point of contact is: Maleah Novak, Project Coordinator, Alcohol and Other Drug Policy Institute 1127

11th St. Ste. 214, Sacramento, CA 95814 FAX: 916-583-7322. Phone: 916-572-8171. Email:

Pursuant to the CCR, Title 9, Division 4, Chapter 8, Section 13010 at least thirty percent (30%) of staff providing

counseling services in all AOD programs licensed and/or certified by DHCS shall be licensed or certified pursuant

to the requirements of this chapter. All other counseling staff shall be registered pursuant to Section 13035 (f).

Licensed professionals my include LCSW, MFT, Licensed Psychologist, Physician, or registered Intern, as

specified in Section 13015.

Please note that effective August 24, 2007, applicants will be assessed an Initial Certification Application Fee in

the amount of $2,664 regardless of the form of organization or ownership.

The application fee will NOT be returned if the application package is withdrawn or denied.

If you have any questions regarding the certification of nonmedical adult residential or outpatient alcoholism or

drug abuse recovery or treatment facilities, or need assistance with your fire clearance, please contact DHCSs

Licensing and Certification Branch at (916) 322-2911.

DHCS 5112 (07/13)

Page 2 of 11

Form Dhcs 5112 - California Initial Certification Application - Health And Human Services Agency Page 2

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