Form Dhcs 5104 - California Department Of Health Care Services

Form Dhcs 5104 - California Department Of Health Care Services - Page 2

State of California—Health and Human Services Agency

Department of Health Care Services

TOBY DOUGLAS

EDMUND G. BROWN JR.

DIRECTOR

GOVERNOR

TO:

LOCAL FIRE AUTHORITY

FROM:

DEPARTMENT OF HEALTH CARE SERVICES

SUBSTANCE USE DISORDER (SUD) COMPLIANCE DIVISION

LICENSING AND CERTIFICATION BRANCH

SUBJECT:

FIRE CLEARANCE

The Department of Health Care Services (DHCS) licenses and certifies residential alcohol and/or

other drug treatment programs and certifies outpatient programs. In an effort to promote program

safety, these programs are required by state regulations and certification standards to obtain a

fire clearance from local fire authorities.

The Department requires the State of California Std. 850 Fire Safety Inspection Request form for

residential programs. However, for outpatient programs, any clearance issued on official

stationary or fire department forms is acceptable. Attached is a sample format, which may also be

used.

Thank you for your cooperation and assistance to DHCS in our efforts to keep our programs

fire-safe. If you have any questions, please contact the Licensing and Certification Branch at

(916) 322-2911.

Attachment

Substance Use Disorder (SUD) Compliance Division

Licensing and Certification Branch, MS 2600

PO Box 997413

Sacramento, CA 95899-7413

Phone: (916) 322-2911

Fax (916) 322-2658

Form Dhcs 5104 - California Department Of Health Care Services - Page 2