California SUD Treatment Program Personnel File Requirements: DHCS Licensing, Certification and Counselor Rules (2026)

California regulates substance use disorder (SUD) treatment programs through the Department of Health Care Services (DHCS), and which personnel rules apply depends on what the program holds:

• A residential license. DHCS "has the sole authority in state government to license adult alcohol or other drug recovery or treatment facilities" (Health and Safety Code (HSC) §11834.01). Licenses run two years at a time (9 CCR §10528) under 9 CCR Division 4, Chapter 5. Every licensed facility also needs a DHCS level of care designation, an ASAM Level of Care Certification, or both (HSC §11834.015; BHIN 21-001).
• Certification. Since AB 118 (2023), every outpatient "alcohol or other drug program" with a California location must be certified by DHCS (HSC §§11832, 11832.2), and programs had to be certified by January 1, 2025 (§11832.25). The operative standards are "DHCS Certification for Alcohol and Other Drug Programs," issued as Attachment 1 to BHIN 25-003 (February 3, 2025). Licensed residential facilities, DUI programs and narcotic treatment programs are exempt from certification but may choose it (§§11832.3(b)(1), 11832.22).
• A narcotic treatment program (NTP) license, issued for no more than one year at a time under 9 CCR Division 4, Chapter 4 (HSC §11839.7(a)(1); 9 CCR §10055(a)), with the rules DHCS rewrote effective October 1, 2025 (BHIN 25-008).

On top of the licensing rules sit three more layers: the counselor registration and certification rules in 9 CCR Chapter 8, which reach every one of these programs; Medi-Cal staffing and credentialing rules for programs that bill Drug Medi-Cal or DMC-ODS; and California employment law, which sets several of the longest retention periods in this guide. Each is covered below, followed by a checklist that marks which layer every item comes from.

Registered before the first session. "Except as set forth in subdivision (d), an individual providing counseling services working within a program described in subdivision (a) shall be registered with, or certified by, a certifying organization approved by the department to register and certify counselors" (HSC §11833(c)(1)). The regulation still prints a six-month window after hire (9 CCR §13035(f)), but DHCS says the statute made it inoperative: "This six (6) month time-period is no longer permissible," and an unlicensed counselor "must be registered or certified with a DHCS approved certifying organization prior to providing counseling services" (MHSUDS IN 18-056). "Counseling services" covers screening and intake, assessment, treatment and recovery planning, individual, group and family counseling, and documenting it all (9 CCR §13005(a)(4)).

Three certifying organizations. DHCS recognizes only CAADE, CADTP and CCAPP; the ten organizations named in 9 CCR §13035(a) are out of date. Each keeps a public registry, so verify the credential there before the first session and again at each expiration date.

The clocks.

• A registrant must "complete certification as an AOD counselor within five (5) years of the date of registration" (9 CCR §13035(f)(1)), counted from initial registration with any approved organization.
• Since January 1, 2026, registration "shall be valid for one (1) year," and a first-year registered counselor must "apply for registration renewal a minimum of one hundred twenty (120) calendar days prior to the expiration date" (BHIN 25-029 §2.C).
• A counselor who first registers on or after July 1, 2025 "must complete a minimum of eighty (80) hours of education, including education in core competency education topics" within six months of registration (BHIN 25-029; HSC §11833(b)(5)). Registered counselors renew with 50 hours of education a year, or 20 once they have completed 315 hours (BHIN 25-029 §3.B). DHCS says it "does not have the authority to grant hardship exceptions" to the 80 hours.
• Certification lasts two years and renews with "a minimum of forty (40) hours of continuing education" (9 CCR §§13050, 13055(a)). A late renewal stops the work: the counselor "shall be prohibited from providing counseling services until and unless their certification is renewed" (MHSUDS IN 18-056).

Exemptions. HSC §11833(d) exempts graduate students completing a practicum in psychology, social work, marriage and family therapy or counseling, associates registered with the Board of Behavioral Sciences (BBS), and licensed professionals "as defined by the department." DHCS still points to 9 CCR §13015(a): physicians licensed by the Medical Board, licensed psychologists, licensed clinical social workers and marriage and family therapists, and interns registered with the Board of Psychology or the BBS. A licensed professional gives the program "a copy of their license to practice in the State of California" for the personnel file and completes 36 hours of continuing education every two years (§13015(c)-(d)). For exempt students and associates, the program collects annual proof of enrollment or BBS registration renewal and removes the person from counseling immediately if that status ends (BHIN 23-008).

Program duties. At least 30 percent of the staff providing counseling services must be licensed or certified (9 CCR §13010(a)). Counselors follow their certifying organization's code of conduct (§13060), and "Within 24 hours of the time an alleged violations [sic] of the code of conduct specified in Section 13060 by a registrant or a certified AOD counselor becomes known to an AOD program, the program shall report it to the Department and to the registrant or counselor's certifying organization" (§13065(a)).

Each license type has its own list, and the lists overlap more than they differ.

Certified programs keep these records for "all staff and/or HCPs," and staff "means employees, interns, or volunteers" (Standards §§37(a), 2(a)(34)), so volunteer and intern files count too. Records may sit at a central administrative location, but a certified program's records must reach the analyst during the visit: "If the personnel records are not received by the conclusion of the site visit, the program shall be cited for a deficiency" (§37(c)).

Code of conduct. Every certified program must keep a staff code of conduct policy in its operations manual (HSC §11832.8(b)(5)). A licensed residential facility that is also certified must have staff "sign, and date, a copy of the code of conduct," with the signed copy in each personnel file (Standards §57(c)-(d)).

Watch for old checklists. Items such as a salary schedule and an "employment confirmation statement" come from the superseded 2004 and October 2023 standards. The DHCS-hosted licensing toolkit still lists them, but the current §37 list does not.

Residential and certified programs: a TB test at hire and every year. For licensed residential staff, good health "shall be verified by a health screening, including a test for tuberculosis, performed under licensed medical supervision not more than sixty (60) days prior to or seven (7) days after employment with tuberculosis testing renewable every year" (9 CCR §10564(e)(1)). The screener signs a report on the person's physical qualifications for the job and any condition that would endanger them, residents or staff (§10564(e)(2)). Residential volunteers sign a statement that they are in good health and take a TB test on the same timing, though the licensee may skip the test for volunteers without "frequent or prolonged contact with residents" (§10564(e)(3)). Certified programs use the same timing, with the screening done "by a primary care provider," and the rule reaches interns and volunteers because they are staff (Standards §§36(d), 2(a)(34)). Neither rule names a test type or requires an annual physical. We found no staff TB requirement in the NTP rules.

Cal/OSHA adds its own. The aerosol transmissible diseases standard lists "Drug treatment programs" among the settings "at increased risk for transmission" (8 CCR §5199(a)(1)(E)). For employees with occupational exposure, the employer makes TB assessment available "at least annually," offers the vaccinations CDPH recommends and seasonal influenza vaccine, has anyone who declines the flu vaccine sign the declination statement, and trains exposed staff at initial assignment and at least annually (§5199(c)(6)-(7), (h)(3), (h)(10)). These are medical records, kept "for at least the duration of employment plus 30 years" (§5199(j)(1)(D)), and California's employment regulations require medical information to be kept "in medical files separate from the employee's personnel file" (2 CCR §11069(g)).

Two California rules shape the records themselves. Since January 1, 2026, an employer that keeps training records must make them show the employee's name, the training provider, "The duration and date of the training," the core competencies covered and "The resulting certification or qualification" (Labor Code §1198.5(a)(2)), and employees may inspect them like the rest of the personnel file. Harassment training documentation must be kept "for a minimum of two years," including names, dates, sign-in sheets, certificates, the materials and the provider (2 CCR §11024(b)(2)), and each employee must "read and to acknowledge receipt of" the anti-harassment policy (§11024(c)(2)(L)).

California's general workplace violence law (Labor Code §6401.9, SB 553) exempts "Health care facilities, service categories, and operations covered by Section 3342," and Cal/OSHA's health care standard names "Drug treatment programs" in its scope (8 CCR §3342(a)(1)(D)). Neither standard defines "drug treatment programs," but the term is listed without qualification and Cal/OSHA's health care fact sheet names it among covered operations, so a DHCS-licensed or certified SUD program should plan on following §3342:

• a written workplace violence prevention plan, specific to its units and services and available to employees at all times (§3342(c));
• a violent incident log recording every incident, response and injury investigation (§3342(d)), and an annual review of the plan with employees (§3342(e));
• initial training for "All employees working in the facility, unit, service, or operation," and refresher training "at least annually" for "Employees performing patient contact activities and those employees' supervisors" (§3342(f)(1)-(2));
• training records kept "for a minimum of one year," with dates, contents, trainers and attendees, and incident records kept five years (§3342(h)).

An outpatient mental-health-only program outside a health facility license appears to fall under Labor Code §6401.9 instead, and a combined mental health and SUD organization can satisfy §6401.9 by applying §3342 everywhere (§6401.9(b)(2)(B)). Sober living homes that provide no treatment and DUI programs are unresolved edge cases.

• Residential administrator. Chapter 5 sets no minimum years of experience. The administrator must "demonstrate abilities and competency" in the required services, the law, directing others, managing the budget, and the ability "to recruit, employ, train, and evaluate qualified staff" (9 CCR §10564(a)(1)). A change of administrator is reported to DHCS within 10 working days with the new administrator's qualifications (§10561(c)(3)).
• Certified program director. At least "two (2) years of work experience in the field of substance use disorders and related behavioral health conditions," with the same competency areas (Standards §36(a)(2)). A change is reported within 10 working days on forms DHCS 5082 and 5085 (§34(d)(3)).
• NTP medical director. "a licensed physician in the State of California with at least one year of experience in treating persons with opioid use disorder" (9 CCR §10110(a), as rewritten by BHIN 25-008). For each physician, nurse practitioner, physician assistant, nurse, psychiatric technician, counselor and pharmacist, the NTP keeps license status, hours, a resume and coverage arrangements "on file at the program facility" (§10130(b)).
• Medi-Cal SUD medical director. A licensed physician who is enrolled in Medi-Cal as an SUD medical director and not excluded (22 CCR §51000.70), with six regulatory duties, who "shall receive a minimum of five (5) hours of continuing medical education in addiction medicine each year" (§51341.1(b)(28)(A)(iii)). DMC-ODS providers also keep the medical director's written roles, responsibilities and code of conduct, "signed and dated by a provider representative and the physician" (DMC-ODS Agreement 2025-26, Att. 2C §22.D.5).

Programs that bill Drug Medi-Cal or the Drug Medi-Cal Organized Delivery System (DMC-ODS) add four kinds of records.

Licensed practitioners of the healing arts (LPHAs). The State Plan list covers physicians, nurse practitioners, physician assistants, registered nurses, registered pharmacists, licensed clinical psychologists, LCSWs, LPCCs, LMFTs, the registered candidates for those three licenses, LVNs, licensed occupational therapists and licensed psychiatric technicians (State Plan TN 23-0026; BHIN 24-023). "An SUD diagnosis may only be made by an LPHA," and when a counselor completes an assessment, "a Licensed Practitioner of the Healing Arts (LPHA) shall review that assessment with the counselor and the LPHA shall make the initial diagnosis" (BHIN 23-068). The two lists do different jobs: being an LPHA for Medi-Cal does not by itself exempt someone from counselor registration, which still follows 9 CCR §13015(a). Candidates who applied for BBS registration within 90 days of their degree can bill while the application is pending, and the program keeps documentation that it was submitted and later approved (BHIN 24-023).

DMC-ODS training and file contents. The 2025-26 DMC-ODS agreement requires "a minimum of five hours of continuing education related to addiction medicine each year" for physicians and for "Professional staff (LPHAs)," two ASAM e-Training modules for staff conducting assessments, and a personnel file "on all employees, contracted positions, volunteers, and interns" with the application or resume, a signed employment confirmation or duty statement, the job description, evaluations, health records, other personnel actions, SUD training, the "Current registration, certification, intern status, or licensure," proof of continuing education, the code of conduct and withdrawal management training records (Att. 2C §§2.A.5-6, 21.C.2, 22.D.1).

Peer support specialists. Only a person with "a current state-approved certification as a Medi-Cal Peer Support Specialist" delivers the service (BHIN 25-010 §6(a)). Certification requires an 80-hour core competency curriculum, an exam and a signed code of ethics, and renewal comes every two years with "20 hours of continuing education every two years, including six hours of law and ethics" (WIC §14045.15; BHIN 25-010 §9(f)). Services run "under the direction of a Behavioral Health Professional," and a peer supervisor completes DHCS-approved supervisor training "within 60 days of beginning to supervise" (§§6(e), 7(b)). CalMHSA's public registry confirms a certification.

County credentialing. Counties verify each licensed, registered or certified provider's credential, education and continuing education "through a primary source," collect a signed attestation, check the Medi-Cal Suspended and Ineligible Provider List, and re-credential "at a minimum every three years" (MHSUDS IN 18-019 for DMC-ODS counties; BHIN 25-015, which replaced BHIN 22-070, for DMC State Plan counties). The provider's files are where that evidence comes from.

DHCS requires background checks in one case. The only DHCS rule requiring criminal record review and fingerprints covers residential facilities that serve adolescents under a waiver: everyone with supervisory responsibility for, or frequent or routine contact with, adolescent residents "shall be subject to a criminal record review prior to their involvement in the provision of services to adolescents," and stays cleared afterward (9 CCR §§10615(b)-(c), 10624(a); HSC §11834.50(c)). We found no DHCS rule requiring background checks of other staff in licensed, certified or narcotic treatment programs, and none that names Live Scan.

The Fair Chance Act limits when everyone else may check. An employer with five or more employees may not ask about or consider conviction history "until after the employer has made a conditional offer of employment" (Gov. Code §12952(a)(2)). To withdraw an offer over a conviction, it makes an individualized assessment, sends a written preliminary notice with a copy of the conviction history report, gives the applicant "at least five business days to respond" (five more if they dispute the report's accuracy), and then sends a written final notice (§12952(c)). The assessment must consider "Whether a disability, including but not limited to a past drug addiction or mental impairment, contributed to the offense or conduct" (2 CCR §11017.1(c)(1)(B)(i)(VI)), which matters in a field that hires people in recovery. The exemption for legally required checks applies only when the employer itself is required to check: "A state, federal, or local law requiring another entity, such as an occupational licensing board, to conduct a criminal background check will not exempt an employer" (§11017.1(a)(5)).

What may never be asked or used. Arrests that did not lead to conviction, diversion programs, sealed or dismissed convictions and juvenile records (Labor Code §432.7), and minor marijuana convictions more than two years old (§432.8). A background report from a screening company needs a stand-alone disclosure and written authorization, and the applicant gets a copy on request (Civ. Code §1786.16).

A program "shall be subject to suspension if claims for payment are submitted for the services" of a person listed on Medi-Cal's Suspended and Ineligible Provider List or the federal OIG list (WIC §14043.61(a); DHCS provider agreement 6208 ¶28.c(5)). DHCS publishes the S&I list monthly and tells providers to check both: "Cross-referencing both lists is recommended." No California statute or DHCS provider agreement sets a screening frequency; counties check S&I status when they credential providers and at re-credentialing, and county contracts may set their own interval. Checking both lists before hire and every month matches how often DHCS updates its list. The OIG exclusion screening guide covers the federal side.

Several California rules set retention, and the longest one that applies wins:

For most programs that means four years for personnel files, measured from the later of when a record was made or the personnel action, and employment plus 30 years for exposure medical records. Records on sex, race or national origin are kept "separately from the employee's main personnel file" (2 CCR §11013(c)(3)).

DHCS reviews licensed residential facilities "at least once during the license period," and "may conduct announced or unannounced site visits" (HSC §11834.01(b)-(c)). Certified programs get "onsite visits for compliance at least once during each certification period," also announced or not (HSC §11832.12), and a site visit may be "a physical or virtual inspection" (Standards §2(a)(32)). NTPs are inspected "not less than annually" (9 CCR §10080(a)). In each case DHCS may interview staff in private and inspect records without the program's consent (9 CCR §10544(c); Standards §27(c)).

Accreditation buys no relief. We found no California statute, regulation or DHCS guidance that gives a CARF- or Joint Commission-accredited program deemed status, fewer reviews or credit toward the personnel rules, and DHCS says it "does not allow waivers or variances." The one recognition is narrow: an ASAM Level of Care Certification, which ASAM developed with CARF, satisfies the DHCS level of care designation for residential programs, except withdrawal management, for which ASAM offers no certification (BHIN 21-001). NTPs need accreditation under federal law to be certified (42 CFR 8.11(a)(2)). The CARF behavioral health guide covers what accreditation adds.

A practical audit of a California SUD program's personnel files runs in five steps:

1. Start from the roster, including interns and volunteers. Certified programs keep files on all of them, residential volunteers need health statements and TB tests, and DMC-ODS files cover contractors too.
2. Check every counselor's credential against the certifying organization's registry, with dates. Registration came before the first counseling service, the registrant is inside the five-year certification window, a first-year registrant applied for renewal at least 120 days before the registration expires, and new registrants finished their 80 hours within six months. Licensed professionals have a copy of their license on file.
3. Check the health and training dates. The TB test fell between 60 days before and 7 days after hire and has been renewed every year; detox, naloxone, MAT, harassment and workplace violence training records show who, what, when and how long.
4. Check the employment-law items. No conviction questions before the conditional offer, Fair Chance notices where an offer was withdrawn, medical records in a separate file, and four-year retention for personnel records.
5. Fix forward and date honestly. A missing record obtained today carries today's date. For a certified program, make sure files can be produced before the analyst's visit ends.

Repeat the audit at least once a year and before each license or certification renewal.