Form SOC171 "Transitional Housing Program-Plus-Foster Care (Thp-Plus-FC) Application - Approval/Denial/Denial Pending Checklist" - California

What Is Form SOC171?

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 May 1, 2012;
  • 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 SOC171 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 SOC171 "Transitional Housing Program-Plus-Foster Care (Thp-Plus-FC) Application - Approval/Denial/Denial Pending Checklist" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TRANSITIONAL HOUSING PROGRAM-PLUS-FOSTER CARE (THP-PLUS-FC) APPLICATION -
APPROVAL/DENIAL/DENIAL PENDING CHECKLIST
Pursuant to the provisions outlined in the Provider Approval Standards, the following has been assessed to approve/deny
application requesting to provide THP-Plus-FC services:
1. APPLICATION
The following has been received:
Completed Application.
I I
Application signed by Executive Director, Chief Executive Officer, or Board of Director Member.
I I
I I
Articles of Incorporation is attached.
I I
Circle that any one or all disclosures are attached to application regarding:
1
Prior or current participation on another non-profit’s Board of Directors;
2. Any Board of Directors or Executive Director that holds beneficial ownership of ten percent or more of
THP-Plus-FC facility or other licensed facility;
3.
Any revocation of approval or other disciplinary action that was or is currently being taken against the
applicant, a member of the Board of Directors, a Corporate Officer, or employee;
4. A copy of a Board of Director’s Minutes stating that the applicant is authorized to apply for approval to
be a THP-Plus-FC provider;
5. Information about the applicant and/or employees including criminal background and Child Abuse
Central Index (CACI) clearances, employment history, education history, and character references
obtained within the last _______ years.
Written statement attached describing how the Board-of-Directors performs duties
I I
1. Include other duties that are outside the scope of the Board of Directors
An attached Plan of Operation.
I I
I I
Copy of the most recent A-133 audit report.
I I
Verification, in writing, of availability of three months of operating capital.
I I
A Secondary County Letter of Support indicating that the applicant will provide services in its county.
If approved, the applicant agrees to cooperate with investigations conducted by the lead/secondary county
I I
approving or placing agencies; agrees to enter into corrective action plans pertaining to violations of approval
standards; and agrees to come into compliance with approval standards in order to remain as a THP-Plus-FC
provider.
2. CRIMINAL RECORD/CACI CLEARANCES
I I
Criminal Record and CACI records per Welfare and Institutions Code section 11403.25 have been obtained for the
provider and staff working with non-minor participants, including exemptions if necessary.
3. INSPECTION OF PROVIDER’S FACILITY
After inspecting provider’s facility, it was noted that the provider had:
I I
Employees employment history and educational background documentation.
Medical screening requirements.
I I
Employee duty statements.
I I
I I
Volunteer records.
I I
Criminal record clearance and CACI check results.
I I
Record of background clearance exemption requests.
System of record retention of non-minor dependent case files.
I I
1. Maintain a List of funds and personal effects being held at the request of the non-minor dependent.
SOC 171 (5/12)
PAGE 1 OF 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TRANSITIONAL HOUSING PROGRAM-PLUS-FOSTER CARE (THP-PLUS-FC) APPLICATION -
APPROVAL/DENIAL/DENIAL PENDING CHECKLIST
Pursuant to the provisions outlined in the Provider Approval Standards, the following has been assessed to approve/deny
application requesting to provide THP-Plus-FC services:
1. APPLICATION
The following has been received:
Completed Application.
I I
Application signed by Executive Director, Chief Executive Officer, or Board of Director Member.
I I
I I
Articles of Incorporation is attached.
I I
Circle that any one or all disclosures are attached to application regarding:
1
Prior or current participation on another non-profit’s Board of Directors;
2. Any Board of Directors or Executive Director that holds beneficial ownership of ten percent or more of
THP-Plus-FC facility or other licensed facility;
3.
Any revocation of approval or other disciplinary action that was or is currently being taken against the
applicant, a member of the Board of Directors, a Corporate Officer, or employee;
4. A copy of a Board of Director’s Minutes stating that the applicant is authorized to apply for approval to
be a THP-Plus-FC provider;
5. Information about the applicant and/or employees including criminal background and Child Abuse
Central Index (CACI) clearances, employment history, education history, and character references
obtained within the last _______ years.
Written statement attached describing how the Board-of-Directors performs duties
I I
1. Include other duties that are outside the scope of the Board of Directors
An attached Plan of Operation.
I I
I I
Copy of the most recent A-133 audit report.
I I
Verification, in writing, of availability of three months of operating capital.
I I
A Secondary County Letter of Support indicating that the applicant will provide services in its county.
If approved, the applicant agrees to cooperate with investigations conducted by the lead/secondary county
I I
approving or placing agencies; agrees to enter into corrective action plans pertaining to violations of approval
standards; and agrees to come into compliance with approval standards in order to remain as a THP-Plus-FC
provider.
2. CRIMINAL RECORD/CACI CLEARANCES
I I
Criminal Record and CACI records per Welfare and Institutions Code section 11403.25 have been obtained for the
provider and staff working with non-minor participants, including exemptions if necessary.
3. INSPECTION OF PROVIDER’S FACILITY
After inspecting provider’s facility, it was noted that the provider had:
I I
Employees employment history and educational background documentation.
Medical screening requirements.
I I
Employee duty statements.
I I
I I
Volunteer records.
I I
Criminal record clearance and CACI check results.
I I
Record of background clearance exemption requests.
System of record retention of non-minor dependent case files.
I I
1. Maintain a List of funds and personal effects being held at the request of the non-minor dependent.
SOC 171 (5/12)
PAGE 1 OF 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TRANSITIONAL HOUSING PROGRAM-PLUS-FOSTER CARE APPLICATION -
APPROVAL/DENIAL/DENIAL PENDING CHECKLIST
4. PROVIDER PLAN OF OPERATION, ONSITE INSPECTION OF THE LIVING SITE
Applicant confirms that it will use the on-site inspection checklist (SOC 174) of the living site, including the building
I I
and grounds that will ensure the health and safety of non-minor dependents living in the placement.
5. YOUNG ADULT'S PERSONAL RIGHTS
I I
The provider agrees to respect the personal rights of the non-minor dependent in foster care as outlined in
Welfare and Institutions Code section 16001.9.
6. COMPLETION OF ORIENTATION/TRAINING
The provider has obtained a copy of Provider Approval Standards and completed the county orientation.
I I
I certify that the above named applicant meets the requirements as a provider of THP-Plus-FC services as outlined in the
program’s Approval Standards.
___________________________________________________________
REVIEWER’S SIGNATURE
(DATE)
The applicant has not completed the application process as required. The following is incomplete:
___________________________________________________________
REVIEWER’S SIGNATURE
(DATE)
The applicant has resubmitted the application and has included the information that was incomplete. The applicant is
therefore approved to provide THP-Plus-FC services.
___________________________________________________________
REVIEWER’S SIGNATURE
(DATE)
The provider has not corrected the incomplete application and therefore DOES NOT meet the requirements of the THP-
Plus-FC approval standards.
___________________________________________________________
REVIEWER’S SIGNATURE
(DATE)
SOC 171 (5/12)
PAGE 2 OF 3
STATE OF CALIFORNIA - HELATH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TRANSITIONAL HOUSING PROGRAM-PLUS-FOSTER CARE APPLICATION -
APPROVAL/DENIAL/DENIAL PENDING CHECKLIST
Review Comments
SOC 171 (5/12)
PAGE 3 OF 3
Page of 3