Blank Dhcs 6002 PDF Template

The attached application is to be used by current and prospective providers that wish to apply for Substance Use Disorder (SUD) treatment program initial residential licensure, initialcertification, merger with another legal entity or change of ownership of an existing facility. Current providers wishing to relocate, add or delete treatment services, increase/decrease treatment beds or change target population must complete the Supplemental Application DHCS 5255 ­ (Rev. 6/16). All items in blue underline throughout the applicationsignifies a link to the specified website.

It is vital that you carefully read each component (including the regulations and/or standards) before beginning to fill out the application. Answer each question in the application, and submit only the documentation requested and required. An incomplete application results in a delay of the application process.

If, after you have read the entire application packet, you determine that you would like technical assistance or training addressing certain elements of the application process, you mayrequest assistance, free of charge, from the Department of Health Care Services (DHCS)consulting agency. Please check the Department's website for the current technical assistance provider.

If you have any questions regarding the licensing or certification of SUD recoveryor treatment facilities, please contact DHCS’s SUD Compliance Division at (916)322­2911.

Public Information

Information provided by the applicant can be made available for public review, unless otherwise exempted by law (Inspection of Public Records, Chapter 3.5, Division 7, GovernmentCode).

Requirements for License

The California Code of Regulations (CCR), Title 9, Division 4, Chapter 5, §10505, states, inpart, that no person, firm, partnership, association, corporation, or local government entity shalloperate, establish, manage, conduct, or maintain an alcoholism or drug abuse recovery or treatmentfacility without obtaining a current, valid license pursuant to thischapter.

An alcoholism or drug abuse recovery, treatment, or detoxification facility is defined as any facility, place or building which provides 24­hour, residential, non­medical services in a group settingto adults. For the purpose of further defining whether licensure is required, alcoholism or drugabuse recovery or treatment services mean services which are designed to promote treatment and maintain recovery from substance use disorder problems which include one or more of the following: detoxification, group sessions, individual sessions, educational sessions, and recovery ortreatment planning.

Regulations

The regulations that govern the licensing of non­medical residential facilities covered by these application instructions are under CCR, Title 9, Division 4, Chapter 5. In order to assist applicants in supplying the detailed information needed in the licensing process, a copy of the regulations maybe downloaded from the California Office of Administrative Law website. The pertinent regulations are listed under the Department and Alcohol and DrugPrograms.

For information on purchasing the regulations, including the receipt of updates, please contact Barclays West Group online or by phone at 1­800­888­3600.

Requirements forCertification

The Health and Safety Code, §11830, offers certification of residential and outpatientprograms on a voluntary basis. Although certification is voluntary, programs wanting to ensure quality assurance, while expanding the availability of funding resources, will requestcertification.

Many programs consider certification advantageous in gaining the confidence of potentialclients, insurance companies, and other third­party payers, as it signifies that a program meets minimal levels of service quality. In addition, many counties require that programs under contract be SUD certified as a condition of receivingfunds.

CertificationStandards

The standards that govern certified programs covered by these instructions are within the Alcohol and Other Drug Certification Standards, and may be downloaded from the DHCS website.

Requirements for Drug Medi­Cal Certification(DMC)

CCR Title 22, offers DMC certification to programs that provide substance abuse servicesto Medi­Cal beneficiaries that are covered by the Medi­Cal program, when it is determined, by a physician, that alcohol and drug treatment is medicallynecessary.

If you intend to provide residential DMC services, you must first complete this application and be issued a residential license prior to submitting an application for DMC residentialservices.

The DMC certification requirements for substance abuse clinics are contained in the DrugMedi­Cal Certification Standards for Substance Abuse Clinics; the Alcohol and/or Other Program Certification Standards; and CCR Title 22, Sections § 51341.1, § 51490.1, and §51516.1.

To assist applicants in supplying the detailed information needed in the DMC certificationprocess, a copy of the regulations and standards can be downloaded from the Drug Medi­Cal Certification page. DMC applications must be submitted separately to:

PROVIDER ENROLLMENT DIVISION

MS 4704 PO Box 997412

Sacramento, CA 95899­7412

(800) 541­5555 or (916) 323­1945

Treatment Provider Application Fees

DHCS assesses fees to all licensed and/or certified residential and certified outpatientSUD recovery and treatment facilities, regardless of the form of organization orownership. Please see the Department's website for the current fee structure.

The application process is normally completed within 120 days. The 120 days beginswhen an application packet is determined to be complete. 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, with the appropriate fee. It is recommended that you retain a copy of the completed application packet for yourrecords.

Once you have determined your application is complete, please mail thecompleted application, documentation, and a check or money order, made out to the Departmentof Health Care Services, to cover the appropriate initial application fee, to the followingaddress:

Department of Health Care Services

Substance Use Disorder Compliance Division

Licensing andCertificationSection

PO Box 997413, MS 2600

Sacramento, California 95899­7413

APPLICATIONINSTRUCTIONS

Please follow these instructions carefully and submit your application only after it has been properly completed, the required supportive documentation has been prepared, and the entire packethas been properly formatted.

Applications received by DHCS that do not meet the requirements described in these instructions will be returned to the applicant, minus any fees, without having been reviewed. The review process will not begin until the application meets submission requirements. If your application is returned without having been reviewed, and you decide not to proceed with the application process, DHCS will refund all fees paid.

Please complete all applicable sections of the application. If a line or question does not apply to you, fill the line or question with “N/A.” If an entire section does not apply to your application, place a check mark in the “N/A” box located in the section heading.

You may attach additional documentation if your information does not fit in the appropriatearea; however, the spaces for the requested information must be completed. The application must be complete or the entire packet will be returned to you without review andprocessing.

The application and all supportive documentation must be printed single sided, with 12 point font on 8 1/2" by 11" white paper. Documentation provided by a third party, such as the lease agreementor fire clearance, must be submitted unaltered and in the original format (size, font, color) it was created. When applying for more than one type of service at a time, (i.e. residential licensure and SUD certification of the same facility, or SUD certification only), complete allthe required sections of the application, prepare the supporting documentation (as listed on the following pages), and submit the entire packet at the sametime.

If you are applying for a license and certification at the same time, please completeone application and submit one set of supportingdocumentation.

SUPPORTING DOCUMENTATION AND DESCRIPTIONS

Due to DHCS’s filing requirements, applications should not be doubled sided, bound, and must not include plastic sheet or page protectors. Each item, as listed below, must be numbered and separated by correspondingly numbered tabbed dividers.

In order to expedite the application process for all applicants, packets not submitted in this order will be rejected without review.

Tab 1 (all applicants) – Initial Treatment Provider Application, Form DHCS 6002 (Rev.06/16).

Tab 2 (all applicants) – Corporations, LLP's, or LLC's must attach their approved articles of incorporation; partnerships must attach the partnership agreement; non­profit organizationsmust attach a copy of the 501(c)(3) filing from the California Secretary of State; sole proprietorsmust attach the Sole Proprietor Supplement. A fictitious business name statement or business licenseis required if the sole proprietor name is different from the name of the facility (see Section Hof instructions).

Tab 3 (all applicants – except governmental entities) – Lease agreement, donated space agreement, or letter from school approving use of space (see Section C of instructions).

Tab 4 (license applicants only) – Bacteriological Analysis of Water, if applicable (see Section D­3of instructions).

Tab 5 (all outpatient applicants) – Fire Clearance (see Section E­5 of instructions).

Tab 6 (all outpatient applicants) – Zoning Clearance (see Section E­6 ofinstructions).

Tab 7 (all applicants) – Table of Administrative Organization – This document must include achart that shows the governing board, advisory groups, including resident council when applicable,and both lines of authority (straight lines) and communication lines (broken lines) to all staff positions.

Tab 8 (all applicants) – Annual Line Item Budget – A line­item budget (projection of revenues and expenditures) for the current fiscal year that correlates with quarterly and annual written operation reports. If the applicant is a nonprofit corporation, the budget must be approved by the board of directors.

Tab 9 (all applicants) – Community Resources – This document shows the community resourcesto be utilized by the facility as part of its program. Provide a copy of this inventory which shall beused as a resource for assisting program participants in securing additional services to meet and maintain their personal well­being while continuing to enhance personaldevelopment.

Tab 10 (all applicants) – Outline of Activities and Services – A written statement listing the activities and services provided by the facility. This statement should include an outline for specific activities and services such as detoxification (if applicable), group and individual sessions, recovery or treatment planning, continuing recovery or treatment planning recreation, self­help activities (AA, NA, CA), and other activities/services being provided by theprogram.

Tab 11(all applicants) – Program Description – A written statement 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 freeenvironment.

Tab 12 (all applicants) – Statement of Program Goals and Objectives – A written statement that includes the program goals (intent or purpose of its existence) and objectives of the facility. The goals and objective should be time­limited, measurable, and outcome objectives that canbe verified in terms of time and results, and that serve as indicators of programeffectiveness.

Tab 13 (all applicants) – Program Evaluation Plan – A written evaluation plan formanagement decision making. Sufficient program data shall be collected to provide a meaningful assessmentof the program’s progress in meeting itsobjectives.

Tab 14 (all applicants) – Program Mission and Philosophy Statement – A written statement(s) describing the program’s mission and philosophy.

Tab 15 – (all applicants) – Continuous Quality Management Plan – Written policies and procedures for continuous quality management, which shall include how the program monitors and/or ensures that participant files are reviewed, that services are provided to participants, the process for achieving objectives identified in the recovery or treatment plan, recovery or treatment plan reviews, and assurances that the participant’s file contains all required documents.

Tab 16 (all applicants) – Job Descriptions – A narrative description of staff needs (i.e., briefly describe staff composition) for each position at the facility (both paid and volunteer),including minimum staff qualifications and lines of supervision for each position.

Tab 17 (all applicants) – Statement of Admission, Readmission and Intake Criteria – A written statement of admission, readmission, and intake policies, procedures and criteria for determining the participant’s eligibility and suitability for services.

Tab 18 (all applicants) – Admission Agreement – A copy of the admission agreement that will be used by the program.

Minimum Requirements for Admission Agreements for License Applicants:

1.Services to be provided;

2.Payment provisions, including amount assessed and payment schedule;

3.Refund policy;

4.Those actions, circumstances or conditions which may result in resident eviction from the facility;

5.The consequences when a resident relapses and consumes alcohol and/or non­health sustaining drugs; and

6.Conditions under which the agreement may be terminated.

Minimum Requirements for Admission Agreements for Certification Applicants:

1.Fees assessed for services provided;

2.Activities expected of participant;

3.Program rules and regulations;

4.Participants’ statutory rights to confidentiality;

5.Participants’ grievance procedure; and

6.Reasons for termination.

The admission agreement must include all required elements for each application type if applying for multiple services, e.g. the admission agreement must include all licensure and certification elements if applying for a license and certification.

LICENSE APPLICANTS ONLY

Tab 19 – Sketch of Building and Grounds – Submit a sketch, preferably on an 8½" x 11” sheet of paper, all building(s) to be occupied, including a floor plan of all rooms intended for resident’s use. A sketch of the grounds must show all buildings, driveways, fences, storage areas, pools,gardens, recreational area and other spaces of the property. All sketches shall show dimensions of eacharea, but need not be to scale. The floorplan shall show the number and location of beds for allresidents, dependent children and staff (if applicable), and other non­ambulatory persons.

Tab 20 – Sample Menu – The total daily diet for residents shall be of the quality andquantity necessary to meet their needs, and shall be made so that each resident has available at least three meals per day. The written menu(s) shall include times of food service, food provided forbreakfast, lunch, and dinner for one week, including the type and availability of snacks.

Tab 21 – Safeguarding of Personal Property of Residents – Describe the process for safeguarding of resident’s personal property accepted by the licensee for safekeeping, if it is the licensee’s policy to accept such valuables.

As previously stated, please see the chart below to ensure you have submitted the appropriate documentation related to yourapplication:

APPLICANT CONTENT GUIDE

X* ­ excludes governmental agencies

The following information matches, in order, the information, sections and numbers on the "Initial Treatment Provider Application" that must be completed. Incomplete applicationswill be returned withoutreview.

SECTION A – APPLICATION INFORMATION

This section must be completed by all applicants

1.Application Type – Check the appropriate box(es) for the service(s) which you are applying for with this application. If you are applying for more than one type of service at the same location check all the boxes that apply.

2.Application Purpose – Check all box(es) best describing the purpose of this application. If youare changing ownership of an existing facility, please list the license and/or certification number of the program that is being abolished. If you are merging this program with another program, please list the license and/or certification number of that program. You must include the change ofownership documents and board resolution documents authorizing the merge and/or sale under Tab #2.

SECTION B – LEGAL ENTITY INFORMATION

This section must be completed by applicants

1.Legal Entity Name – Enter the legal entity name. Below are specified instructions for:

Corporation only: For a corporation or Limited Liability Company (LLC) of any type this box must match exactly the name of the corporation (or LLC) as filed withthe Secretary of State (SOS) and on the entities articles ofincorporation.

Partnership only: For a partnership that has filed a certification of limited partnershipwith the SOS, this box must match exactly the name filed. For a partnership of any typethat has not filed a certification of limited partnership with the SOS, this box must containthe surnames of the partners.

Sole Proprietor only: For a sole proprietorship, this box must be the full legal name ofthe sole proprietor and include the Sole Proprietor Supplement. A fictious business name statement or business license is required if the sole proprietor name is different fromthe name of the facility.

If the entity has filed any of the above mentioned documents with the SOS, you can look upyour entities legal name at the SOS website. The entities status with the SOS must remain validand active during the licensing or certification period.

2.Program/Facility Name – Enter the name of the Program/Facility. Do not include the legal entity name in this box unless the Program/Facility name is the same as the legal entity name. Do not include the words or abbreviation for “Doing Business As” unless you actually intend to use those words or the abbreviation in the program’s name.

Below are specified instructions for:

Sole proprietors only: Must submit a copy of the fictitious business name statement if different from their full legal name.

3.Administrative/Corporate Address – This box must contain the physical address of the legal entities main office. This address may match the programs address if the entity does not have a separate Administrative/Corporate address. P.O. Boxes or other mail receipt addresses will not be accepted as an administrative address; however, a P.O. Box may be used as a mailing address, as identified in instruction #5 below.

3a. Room/Suite – If applicable, enter the room or suite number of the administrative/ corporate address.

3b. City – Enter the city of the administrative/corporate address.

3c. State – Enter the state of the administrative/corporate address.

3d. Zip code (zip) – Enter the zip code of the administrative/cooperate address.

4.Entity/Program Website Address – If the legal entity has a website, the website must be entered in this box. If the entity has a website and has a separate website specifically for the program, please enter both website addresses. If the entity/program has no website, enter “None” in this box.

5.Mailing Address – Enter the facility’s mailing address. P.O. Box maybe used as a mailing address. Note: The department will use this address to send all official mail.

5a. Room/Suite – If applicable, enter the room/suite number of the mailing address. 5b. City – Enter the city of the mailing address.

5c. State – Enter the state of the mailing address

5d. Zip code (zip) – Enter the zip code of the mailing address.

6.Entity Type – Check the box that describes the type of legal entity in which yourorganization operates. Below are specified instructions for:

Corporation, LLC, or Limited Liability Partnership (LLP) – For a corporation of any type, LLC, or LLP include the articles of incorporation under Tab #2.

Partnerships or General Partnership – For a partnership of any type include the partnership agreement under Tab #2. If the entity is registered with the SOS, include the articles of incorporation under Tab #2.

Sole Proprietor only – Submit a copy of the fictitious business name statement or business license if different from your full legal name.

Governmental Entities only – Governmental entities do not need to provide documentation.

7.Type of Organization – Check the box that describes the tax status of your entity. If you check ‘other’, please give a detailed description, including the government entity that granted the status. Below are specified instructions for:

Non­profit organizations only – must include a copy of the 501(c)(3) filing from the California Secretary of State under Tab #2.

8.Does the applicant currently hold any licenses or certifications issued by DHCS (or the former Department of Alcohol and Drug Programs) or the Department of Social Services (DSS)? – Check ‘Yes’ if your legal entity has any other programs currently licensed and/or certified by the listed departments; check ‘No’ if not. If you check ‘Yes’ enter the license, certification and/or DMC billing number of all of your other facilities and select the type of facility from the drop down list. For entities with more facilities than the form allows, please attach a separate list of all licensed and/or certified facilities, their license number(s), certification(s) and/or DMC billing numbers, including the type of license and/or certification that has been issued under Tab#1.