Form Dhcs 5112 - California Initial Certification Application - Health And Human Services Agency Page 8
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11STATE 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
2.
EXECUTIVE/PROGRAM DIRECTOR:
(Name)
(Title)
(Telephone)
(E-mail Address)
3.
PROGRAM CONTACT PERSON:
(Name)
(Title)
(Telephone)
(E-mail Address)
4.
LEGAL OWNER INFORMATION:
(Legal name, if corporation, the name filed with Secretary of State):
(Name and title of the officer or employee who acts on behalf of the corporation or association)
(Street Address)
(City/State)
(Zip)
5.
TYPE OF ORGANIZATION:
Profit Corporation
Nonprofit Corporation
Government Entity
Sole Proprietor
Partnership
6.
TYPE OF ALCOHOL AND/OR OTHER DRUG SERVICES PROVIDED:
A.
Residential
C.
Nonresidential
B.
Residential Detoxification
1.
Day Treatment
2.
Outpatient
3.
Detoxification
(If detoxification services are provided, please include protocol as required in Section B
Supportive Documents, items 3, 6, 7, 8, and 10)
7.
TARGET POPULATION TO BE SERVED:
1.1 Co-ed
1.2 Men only
1.3 Women only
1.4 Parents/Children
1.5 Youth/Adolescents
1.6 Elderly
1.7 Families
1.8 Dual Diagnosis
Other
If other, please identify:
8.
HOURS OF OPERATION:
24-HOUR FACILITY
YES
NO
(If less than 24-hour operation provide specific hours of operation)
Monday:
Thursday:
Sunday:
Tuesday:
Friday:
Wednesday:
Saturday:
DHCS 5112 (07/13)
Page 8 of 11
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