COUNTY OF LOS ANGELES – DEPARTMENT OF PUBLIC HEALTH
SUBSTANCE ABUSE PREVENTION AND CONTROL
NAME OF ORGANIZATION:
NAME AND POSITION TITLE OF CONTACT PERSON FOR THIS SURVEY:
CURRENTLY A PROVIDER IN GOOD STANDING WITH ALL COUNTY CONTRACTS (i.e. no CARD
designation, State suspensions, current investigations, etc.): Yes  No

If No, please explain. ___________________________________________________________
CURRENT DMC CERTIFICATION: Yes  No 
If Yes, for what DMC program services is the program certified to provide? (Check all that apply)
 Outpatient Treatment Services
 Intensive Outpatient Treatment
 Narcotic Treatment Programs
 Perinatal Outpatient Treatment
 Perinatal Intensive Outpatient Treatment
If no, for what DMC program services will the program seek DMC certification under the expanded
services available under the DMC-ODS waiver? (Check all that apply)
 Outpatient Treatment Services
 Intensive Outpatient Treatment
 Residential Treatment
 Residential Withdrawal Management
 Narcotic Treatment Programs
Is your agency accredited? Yes  No
 Perinatal Outpatient Treatment
 Perinatal Intensive Outpatient Treatment
 If Yes, with what accrediting organization(s):
_______________________________________________________________________________
TYPE(S) AND AMOUNT OF FUNDING NEEDED:
Which type of assistance would your organization need to participate in the DMC-ODS waiver
program (check one or both)?
 Bridge Augmentation for Residential Services (program must be a SAPC-contracted provider
of residential services in good standing)
 Technology Capacity Building
If additional funding were to be made available, what would be the annual amount needed?
Bridge Augmentation for Residential Treatment Services:
Annual Amount Needed: FY 2015-16______________ FY 2016-17 ________________
Technology Infrastructure Capacity Building
Annual Amount Needed: FY 2015-16______________ FY 2016-17 ________________
DESCRIPTION OF HOW FUNDING COULD BE USED:
Residential Treatment Services
Population to be served: Adult  Adolescent  Both  (check one)
Will a specific underserved population be served? Yes  No

If Yes, please list which population(s): _____________________________
Total number of State-licensed capacity (beds) for the residential treatment program per facility
location:
Facility 1:
Adolescents _____
Adults ______
Facility 2:
Adolescents _____
Adults ______
Facility 3
Adolescents _____
Adults ______
Total number of SAPC-contracted beds:
Facility 1:
Adolescents _____
Adults ______
Facility 2:
Adolescents _____
Adults ______
Facility 3
Adolescents _____
Adults ______
If additional funding was to be made available, what would be the requested number of beds for
each residential facility location?
Facility 1:
Adolescents _____
Adults ______
Facility 2:
Adolescents _____
Adults ______
Facility 3
Adolescents _____
Adults ______
Address (es) of licensed facility/facilities where the services will be offered:
Adolescents:
_____________________________________________________________________________
_____________________________________________________________________________
Adults:
_____________________________________________________________________________
_____________________________________________________________________________
If additional funding were to be made available, how might these additional funds be used? (use
additional pages, as needed):
Describe any extraordinary circumstances for the need for funding:
Additional Capacity Building Assistance
Please identify which of the following training and technical assistance areas you are most
interested in receiving (Check all that apply)
 Building an effective Board of Directors
 Preparing the application for DMC Residential License
 Effective Business Planning and Fiscal Operations to operate in the Medi-Cal system
 Recruiting, developing, and retaining staff under DMC ODS
 Improving Financial Management/Internal Controls
 Increasing referrals and accessibility of services
 Designing program services to meet the clinical standards for DMC ODS (e.g. using the
ASAM Criteria in clinical practice, effective treatment planning and documentation, etc.)
 Selecting, acquiring, and implementing an Electronic Health Record System
 Network development/participation in a regional coordinated service network
 Other, please describe__________________________________________
Technology Infrastructure Capacity Building (for residential and/or non-residential treatment
programs, especially those programs not yet DMC-certified)
SAPC-contracted service modality: ________________________________________________
Please indicate how additional funds might be used:
 Purchase computers and other equipment – Describe needed purchases.
___________________________________________________________________________________________
____________________________________________________________________________
 Consultation for organizational information systems design.
 Consultation to upgrade current organizational information system to meet new health
integration requirements.
 Consultation for administrative capacity building for the DMC ODS transformation.
 Consultation for business/fiscal administrative capacity building for DMC ODS.
 Other (please describe): ______________________________________________________
Attach a brief categorical budget and narrative describing how additional funds would be used
in each year.
Technical Assistance Provided by the SAPC-Designated Consultant
If additional funds were to be made available, would your organization agree to the following
provisions as a condition for receiving such funds? Yes  No 
1. To actively seek Drug Medi-Cal certification for the residential facilities receiving bridge
augmentation so that the program is able to provide residential services under DMC by no
later than July 1, 2017;
2. To fully participate in capacity building/technical assistance services offered by an organization
contracted by SAPC in support of this effort where augmentation are for bridge funding for
residential services;
3. To actively seek DMC certification where information technology infrastructure investment
funds are awarded to provide DMC services by no later than July 1, 2017;
4. To assign lead staff (minimum manager-level) who will lead the DMC certification
effort/infrastructure capacity building for the full duration of the project period; and
5. To submit quarterly progress reports and a final report to SAPC and to participate in periodic
provider meetings according to instructions provided when funds are awarded.
6. To relinquish or return funds if the organization decides not to pursue DMC certification, fails
to provide timely progress reports, or fails to actively fulfill any of the preceding five
conditions.
__________________________________________________
Print Name and Title of Person Completing Survey
______________________
Date
__________________________________________________
Signature of Person Completing Survey
______________________
Date
Return the completed survey by 5:00 p.m. on December 8, 2015 to:
Substance Abuse Prevention and Control
County of Los Angeles Department of Public Health
1000 South Fremont Avenue, Building A-9 East, Third Floor
Alhambra, California 91803
Attention: Wayne K. Sugita, Deputy Director
Or send the completed survey electronically to DPH-SAPC@ph.lacounty.gov by the indicated deadline.
THANK YOU VERY MUCH FOR YOUR RESPONSE.