Form SR1a "Short-Term Residential Therapeutic Program (Strtp) Rate Application (Sr 1a)" - California

What Is Form SR1a?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2017;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SR1a by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form SR1a "Short-Term Residential Therapeutic Program (Strtp) Rate Application (Sr 1a)" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SHORT-TERM RESIDENTIAL THERAPEUTIC PROGRAM (STRTP)
TYPE OF APPLICATION (Check one only)
NEW PROGRAM
RATE APPLICATION (SR 1A)
LIC. CAP. CHANGE
BIENNIAL
NEW PROVIDER
RELOCATION
SUBMIT ONE FOR EACH PROGRAM (PRINT OR TYPE)
PROPOSED EFFECTIVE DATE:
REINSTATE
(1) PROVIDER/LICENSEE NAME:
(2) PROGRAM NAME, IF ANY:
(3) PROGRAM NUMBER:
(4) MAILING ADDRESS - NUMBER, STREET:
(5) CITY:
(5a) STATE:
(5b) ZIP CODE:
(6) EXECUTIVE DIRECTOR NAME:
(6a) PHONE:
(6b) E-MAIL:
(7) CCL APPROVED ADMINISTRATOR NAME:
(7a) PHONE:
(8) CONTACT PERSON FOR THIS RATE APPLICATION,
(8a) PHONE:
(8b) E-MAIL:
IF OTHER THAN ABOVE:
(9) BOARD PRESIDENT:
(9a) PHONE:
(10) THE AGENCY IS A NON-PROFIT ORGANIZATION
NO
YES
(11) DOES THIS AGENCY OPERATE ANY OTHER FOSTER CARE BUSINESSES?
NO
YES
(12) IF YES, SPECIFY TYPE OF FOSTER CARE BUSINESS: _____________________________________________________
____________________________________________________________________________________________________
(13) Total licensed capacity of facility(ies) used by this program: ___________ (List facility(ies) on Page 2 of SR 1A.)
CERTIFICATIONS:
I certify that all information contained in the program statement previously submitted remains the same.
YES
NO
If no, attach a new program statement. (LIC 9106)
I understand that the information contained in this document is correct to the best of my knowledge and that submission of false or
misleading information may be prosecuted as a crime.
(14) SIGNATURE OF EXECUTIVE DIRECTOR OR AUTHORIZED BOARD OFFICER:
(15) TITLE:
(16) COUNTY AND STATE WHERE SIGNED:
(17) DATE:
CDSS USE ONLY
PROGRAM IDENTIFIER:
POSTMARK DATE:
DATE RECEIVED:
DATE ASSIGNED:
COUNTY:
CCL DIST:
ANALYST:
RATE TYPE:
FY:
RATE NUMBER:
INTAKE INITIALS:
SR 1A (4/17)
Page 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SHORT-TERM RESIDENTIAL THERAPEUTIC PROGRAM (STRTP)
TYPE OF APPLICATION (Check one only)
NEW PROGRAM
RATE APPLICATION (SR 1A)
LIC. CAP. CHANGE
BIENNIAL
NEW PROVIDER
RELOCATION
SUBMIT ONE FOR EACH PROGRAM (PRINT OR TYPE)
PROPOSED EFFECTIVE DATE:
REINSTATE
(1) PROVIDER/LICENSEE NAME:
(2) PROGRAM NAME, IF ANY:
(3) PROGRAM NUMBER:
(4) MAILING ADDRESS - NUMBER, STREET:
(5) CITY:
(5a) STATE:
(5b) ZIP CODE:
(6) EXECUTIVE DIRECTOR NAME:
(6a) PHONE:
(6b) E-MAIL:
(7) CCL APPROVED ADMINISTRATOR NAME:
(7a) PHONE:
(8) CONTACT PERSON FOR THIS RATE APPLICATION,
(8a) PHONE:
(8b) E-MAIL:
IF OTHER THAN ABOVE:
(9) BOARD PRESIDENT:
(9a) PHONE:
(10) THE AGENCY IS A NON-PROFIT ORGANIZATION
NO
YES
(11) DOES THIS AGENCY OPERATE ANY OTHER FOSTER CARE BUSINESSES?
NO
YES
(12) IF YES, SPECIFY TYPE OF FOSTER CARE BUSINESS: _____________________________________________________
____________________________________________________________________________________________________
(13) Total licensed capacity of facility(ies) used by this program: ___________ (List facility(ies) on Page 2 of SR 1A.)
CERTIFICATIONS:
I certify that all information contained in the program statement previously submitted remains the same.
YES
NO
If no, attach a new program statement. (LIC 9106)
I understand that the information contained in this document is correct to the best of my knowledge and that submission of false or
misleading information may be prosecuted as a crime.
(14) SIGNATURE OF EXECUTIVE DIRECTOR OR AUTHORIZED BOARD OFFICER:
(15) TITLE:
(16) COUNTY AND STATE WHERE SIGNED:
(17) DATE:
CDSS USE ONLY
PROGRAM IDENTIFIER:
POSTMARK DATE:
DATE RECEIVED:
DATE ASSIGNED:
COUNTY:
CCL DIST:
ANALYST:
RATE TYPE:
FY:
RATE NUMBER:
INTAKE INITIALS:
SR 1A (4/17)
Page 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PROGRAM NUMBER:
PROPOSED EFFECTIVE DATE:
(18) Data for each facility location for this STRTP program. Attach additional pages if needed.
LICENSE
ZIP
LICENSED
NUMBER, STREET
CITY
NUMBER
CODE
CAPACITY
(19) LIST PLACEMENT AGENCIES USING THIS PROGRAM. LIST PRIMARY USER FIRST AND OTHERS IN DESCENDING ORDER OF USAGE.
(20) LIST THE COUNTY (IES) YOU HAVE A MENTAL HEALTH CONTRACT AND OR CERTIFICATION WITH. (SPECIFY IF IT IS A CONTRACT OR CERTIFICATION)
SR 1A (4/17)
Page 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STRTP RATE APPLICATION INSTRUCTIONS
(DO NOT RETURN THIS PAGE WITH APPLICATION)
Line 1
Licensee/Corporate Name: Enter the licensee/corporate name shown on the STRTP license. If the provider has licenses with different names, use the
organization or corporate name.
Line 2
Program Name: Enter program name, if any.
Line 3
Program Number: Enter 8 digit number previously assigned by Foster Care Rates. For a new provider application: leave blank.
Line 4
Mailing Address: Enter the number and street (or post office box).
Line 5
City: Enter name of the City.
Line 5a
State: Enter the two digit abbreviation for the State.
Line 5b
Zip Code: Enter the zip code.
Line 6
Executive Director Name: Enter the name of the Executive Director or authorized Board Officer of the organization.
Line 6a
Phone: Enter the telephone number.
Line 6b
E-mail: Enter the email address of the person identified in Line 6.
Line 7
CCL Approved Administrator Name: Enter name of current administrator who has been approved by CCL.
Line 7a
Phone: Enter the telephone number of the administrator.
Line 8
Contact Person For This Rate Application, If Other Than Above: Enter the name of the person who prepared the rate application and to whom questions concerning
the application should be addressed.
Line 8a
Phone: Enter the telephone number of the contact person.
Line 8b
E-mail: Enter the email address of the contact person.
Line 9
Board President: Enter the name of the corporation’s Board President.
Line 9a
Phone: Enter the telephone number of the Board President.
Line 10
Indicate whether or not your organization is a non-profit organization
Line 11
Agency Activities: Check the appropriate box in response to the question “Does this agency operate any other businesses?”
Examples of other businesses are: daycare, on-site school, adult care, Foster Family Agency, Thrift Shop.
Line 12
If yes, specify type of foster care business.
Line 13
Enter total licensed capacity of facilities used by this program.
CERTIFICATION SECTION:
After the STRTP Program Rate Application (SR 1A) is prepared, the executive director or authorized officer must sign the application.
Line 14
Signature: Enter signature of Executive Director or authorized officer.
Line 15
Title: Enter title of person who signed #14.
Line 16
County and State: Enter County and State where application signed.
Line 17
Date: Enter date application signed.
Line 18
Complete all columns for each of your facilities (attach additional pages if necessary).
Line 19
List the county agency(ies) that place children in your facilities.
Line 20
List the county (ies) you have mental health contract or certification with.
SR 1A (4/17)
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