State of California
Health and Human Services Agency
Department of Health Care Services
APPLICATION FOR CERTIFICATION OF
SOCIAL REHABILITATION PROGRAM SERVICES
INSTRUCTIONS: Attach this form with the facility’s written program plan and one duty statement for each staff position
title below.
Please send application to: Department of Health Care Services
Mental Health Services Division
Program Certification Unit
P.O. Box 997413, MS 2800
Sacramento, CA 95899-7413
Email: MHCU@dhcs.ca.gov
FACILITY NAME AND ADDRESS
TELEPHONE & FAX
PROGRAM TYPE
(one program type per application)
SHORT-TERM CRISIS
TRANSITIONAL
LONG TERM
PROPOSED
NUMBERS OF
BEDS
Will this facility use funds awarded by the Mental Health
Wellness Act of 2013 authorized under Senate Bill 82?
YES
NO
Have you filed your licensing application with the CA Dept. of
Social Services Community Care Licensing? If so, please
provide the date submitted.
YES
NO DATE:
ADMINISTRATIVE STAFF INFORMATION: (Include Administrator, Program Director, Clinical Staff, and Consultants)
NAME
HIRE DATE
DEGREE
YEARS WORKED WITH
MENTALLY DISABLED
Attach additional page if more space is needed.
ADMINISTRATOR’S SIGNATURE
DATE
*Special Note
List education in terms of highest degree completed (MA, BA, high school, GED).
Experience working in a program serving people with mental disabilities, in the direct provision of services to
clients, expressed in years and months.
DHCS 1734 (05/19)
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State of California
Health and Human Services Agency
Department of Health Care Services
WRITTEN PROGRAM PLAN FOR SOCIAL REHABILITATION PROGRAMS
(To be included with application for program certification)
1)
Written medical psychiatric policies and practices in the health care and monitoring of medication of clients, as required
by Section 532.1.
2)
Financial records and financial plan of facility operations, as required by Section 533 (a)(2) and 533(d). Please include a
copy of the program or agency’s most recent financialaudit.
3)
Written description of range of program services offered, as required by Section 532.
4)
Length of stay of clients, as required by Section531.
5)
Written policy of arrangements with consultants and involvement of community resources for clients, as required by
Section 532.2(d) and (e).
6)
Written plan of supervision and in-service training of staff, as required by Sections 532.2(g), and 532.6(h) and (j).
7)
Statement of purposes, profile of program services and goals, as required by Section 533(a)(1).
8)
Statement of admission and discharge criteria, including policy and procedure for orienting new clients, as required by
Section 532.3(a), (b), and (c), include copy of admissionagreement.
9)
Organization chart.
10)
Ratios of clients to direct program staff include latest 2 weeks staffing schedule.
11)
Interdisciplinary professional staff resources and workschedules.
12)
Facility’s acknowledgment of, and procedures for implementation of client’s rights (Title 22, Section 72453).
13)
Statement of how clients are involved in the development and implementation of his/her treatment plan.
14)
It is the responsibility of the facility to update the Department of Health Care Services of any changes in the above
criteria within 30 days.
*All citations referenced are California Code of Regulations (CCR), Title 9 unless
otherwise indicated.
DHCS 1734 (05/19)
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