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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

Procedure for Obtaining Certification

The Initial Certification Application Section A and B documents must be completed and submitted to DHCS with

this form (DHCS 5112) and a check or money order, made out to the DHCS Substance Use Disorder

Compliance Division, to cover the $2,664 initial application fee. The application fee is non-refundable. The

review of the application cannot begin until all the necessary documents and fees have been received by DHCS.

In addition, applicants must pass an on-site inspection by an DHCS licensing analyst. Once the application is

complete, an on- site review will be scheduled to determine your ability to comply with the Department's Alcohol

and/or Other Drug Program Certification Standards. Once the on-site review is complete and any deficiencies

found are corrected, a Biennial Certification Fee in the amount of $3452.00 will be due prior to issuance of a

certification. The certification will then be valid for two (2) years, provided there are no compliance issues, after

which time certified programs will be required to submit a renewal application for review and approval along with

the appropriate biennial certification fee.

Certification Application Processing

The Section A and B documents must be submitted in the same sequence as they are in the application booklet.

Sign all documents in BLUE ink.

Do not bind the application documents or place them in a protective

covering. To prevent delays, be sure that all the required documentation is completed, properly signed, with

original signatures, dated, and submitted in the proper format and sequence and that the appropriate fee has

been submitted to the DHCS Substance Use Disorder Compliance Division. It is recommended that you retain a

copy of the completed application packet for your records.

The certification process is normally completed within 120 days. The 120 days begins when an application

packet is determined to be complete.

Please mail a check or money order, made out to the DHCS Substance Use Disorder Compliance Division, to

cover the appropriate initial application fee, the completed application forms contained in Section A and the

documents required in Section B in one complete packet to:

Department of Health Care Services

Licensing and Certification Branch, MS 2600

PO Box 997413

Sacramento, CA 95899-7413

Public Information

Information provided by the applicant(s) for licensure can be made available for public review unless otherwise

exempted by law (Inspection of Public Records, Chapter 3.5, Division 7, Government Code).

Application Fees

On August 24, 2007, Chapter 177, Statutes of 2007, (Senate Bill 84), was enacted mandating DHCS to assess

fees to all licensed and/or certified residential and certified outpatient Alcohol and Other Drug (AOD) recovery and

treatment facilities regardless of the form of organization or ownership. For more information please refer to ADP

Bulletin Number 07-11, entitled Assessment of Fees for Licensure and Certification of Residential and Outpatient

DHCS 5112 (07/13)

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Form Dhcs 5112 - California Initial Certification Application - Health And Human Services Agency Page 3