Form LIC281E "Application and Supporting Documentation Checklist - Short-Term Residential Therapeutic Program" - California

What Is Form LIC281E?

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 January 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 LIC281E by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
APPLICATION AND SUPPORTING DOCUMENTATION CHECKLIST
Short-Term Residential Therapeutic Program
This checklist is intended to assist an applicant in completing and submitting an initial application package and may also be
used to submit revised/updated information to the Department by a licensed Short-Term Residential Therapeutic Program.
FACILITY INFORMATION
(Please type or print clearly.)
Applicant/Licensee Name
Facility License Number , If known
Applicant/Licensee Mailing Address
Contact Person Name
Phone Number
Title
For each form or document submitted, please check “initial” for new application. For a current licensee, please check “revised”
and note the revision date, if you are updating information contained in any of the forms or documents listed below. The following
pages of the Application and Supporting Documentation checklist include a detailed description of the content below.
APPLICATION AND SUPPORTING DOCUMENTATION
Date:
1.
Application for Community Care Facility (LIC 200)
Initial /
Revised
2.
Orientation Certificate
Date Completed:
3.
County Letter of Recommendation
Date of Letter:
4.
Applicant Information (LIC 215)
Initial /
Revised
Date:
5.
Designation of Facility Responsibility (LIC 308)
Initial /
Revised
Date:
6.
Affidavit Regarding Client Cash Resources (LIC 400)
Initial /
Revised
Date:
7.
Surety Bond (LIC 402)
Initial /
Revised
Date:
8.
Monthly Operating Statement (LIC 401)
Initial /
Revised
Date:
9.
Supplemental Financial Information (LIC 401A)
Initial /
Revised
Date:
10.
Balance Sheet (LIC 403)
Initial /
Revised
Date:
11.
Balance Sheet Supplemental Schedule (LIC 403A)
Initial /
Revised
Date:
12.
Financial Information Release And Verification (LIC 404)
Initial /
Revised
Date:
)
13.
Personnel Report (LIC 500
Initial /
Revised
Date:
14.
Personnel Record (LIC 501)
Initial /
Revised
Date:
15.
Health Screening Report Facility Personnel (LIC 503)
Initial /
Revised
Date:
16.
Criminal Record Statement (LIC 508)
Initial /
Revised
Date:
17.
Emergency Disaster Plan (LIC 610C)
Initial /
Revised
Date:
18.
Fire Inspection (LIC 9054)
Initial /
Revised
Date:
19.
Board of Directors Statement (LIC 9165 contained in PUB 326)
Initial /
Revised
Date:
20. Control of Property
Initial /
Revised
Date:
21. Bacterial Analysis of Water
Date:
Initial /
Revised
22. Application or Documentation of Accreditation
Initial /
Revised
Date:
23. Plan of Operation/Program Statement (LIC 9106A)
Initial /
Revised
Date:
LIC 281E (1/17) (PUBLIC - OPTIONAL)
PAGE 1 of 8
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
APPLICATION AND SUPPORTING DOCUMENTATION CHECKLIST
Short-Term Residential Therapeutic Program
This checklist is intended to assist an applicant in completing and submitting an initial application package and may also be
used to submit revised/updated information to the Department by a licensed Short-Term Residential Therapeutic Program.
FACILITY INFORMATION
(Please type or print clearly.)
Applicant/Licensee Name
Facility License Number , If known
Applicant/Licensee Mailing Address
Contact Person Name
Phone Number
Title
For each form or document submitted, please check “initial” for new application. For a current licensee, please check “revised”
and note the revision date, if you are updating information contained in any of the forms or documents listed below. The following
pages of the Application and Supporting Documentation checklist include a detailed description of the content below.
APPLICATION AND SUPPORTING DOCUMENTATION
Date:
1.
Application for Community Care Facility (LIC 200)
Initial /
Revised
2.
Orientation Certificate
Date Completed:
3.
County Letter of Recommendation
Date of Letter:
4.
Applicant Information (LIC 215)
Initial /
Revised
Date:
5.
Designation of Facility Responsibility (LIC 308)
Initial /
Revised
Date:
6.
Affidavit Regarding Client Cash Resources (LIC 400)
Initial /
Revised
Date:
7.
Surety Bond (LIC 402)
Initial /
Revised
Date:
8.
Monthly Operating Statement (LIC 401)
Initial /
Revised
Date:
9.
Supplemental Financial Information (LIC 401A)
Initial /
Revised
Date:
10.
Balance Sheet (LIC 403)
Initial /
Revised
Date:
11.
Balance Sheet Supplemental Schedule (LIC 403A)
Initial /
Revised
Date:
12.
Financial Information Release And Verification (LIC 404)
Initial /
Revised
Date:
)
13.
Personnel Report (LIC 500
Initial /
Revised
Date:
14.
Personnel Record (LIC 501)
Initial /
Revised
Date:
15.
Health Screening Report Facility Personnel (LIC 503)
Initial /
Revised
Date:
16.
Criminal Record Statement (LIC 508)
Initial /
Revised
Date:
17.
Emergency Disaster Plan (LIC 610C)
Initial /
Revised
Date:
18.
Fire Inspection (LIC 9054)
Initial /
Revised
Date:
19.
Board of Directors Statement (LIC 9165 contained in PUB 326)
Initial /
Revised
Date:
20. Control of Property
Initial /
Revised
Date:
21. Bacterial Analysis of Water
Date:
Initial /
Revised
22. Application or Documentation of Accreditation
Initial /
Revised
Date:
23. Plan of Operation/Program Statement (LIC 9106A)
Initial /
Revised
Date:
LIC 281E (1/17) (PUBLIC - OPTIONAL)
PAGE 1 of 8
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
INTRODUCTION
These instructions are intended to help you file an application for a Short-Term Residential Therapeutic Program (STRTP)
license. The above checklist guides an applicant in filing the application. Before a license can be issued, the licensing agency
must review the Application and Supporting Documentation submitted to verify you meet the minimum requirements for
the license.
The initial application fee plus all Application and Supporting Documentation, including the Plan of Operation and Program
Statement must be completed and sent to the licensing agency as a packet. The application fee is non-refundable. Your
application cannot be started until all the forms are filed with the licensing agency. The STRTP shall submit a copy of its
program statement to all county placing agencies with which placements are coordinated or services provided for, including the
county in which the facility is located, for optional review when the STRTP updates its plan of operation/program statement.
Once the letter of recommendation(s) has been received, the initial application (LIC 200) must be filled out with the attached
Letter of recommendation(s), and submitted to the licensing agency for review.
Submit two complete copies of all Application and Supporting Documentation in the same sequence as they are listed above,
tabbed and in binders. If the forms are incomplete, the licensing agency may return the packet to you. To prevent delays, be
sure that you have all the necessary information completed, properly signed, with original signatures, and dated. Make a
photocopy of your Application and Supporting Documentation before you give it to the licensing agency.
CREDIT REPORT - The purpose of a consumer credit report is to report your credit history and whether or not you repay loans
on time for the things you buy.
Your rights of privacy are protected by law. The Department of Social Services obtains credit reports per Section 604 of the Fair
Credit Reporting Act:
“A consumer reporting agency may furnish a consumer report under the following circumstances and no other :...(3) To a person
which it has reason to believe… (D) intends to use the information in connection with a determination of the consumer’s
eligibility for a license or other benefit granted by a governmental instrumentality required by law to consider an applicant’s
financial responsibility or status:…”
Your consumer credit report is maintained in the confidential section of your facility file which is maintained in your local
regional office.
REGULATIONS - The regulations that govern STRTPs covered by these application instructions are under California Code of
Regulations, Title 22, Division 6 and interim licensing standards, Chapter 7.5 Short-Term Residential Therapeutic Program,
Articles 1-10.
Copies of the regulations and amendments can be downloaded from
http://www.cdss.ca.gov/cdssweb/PG71.htm.
LIC 281E (1/17) (PUBLIC - OPTIONAL)
PAGE 2 of 8
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
APPLICATION AND SUPPORTING DOCUMENTATION – DESCRIPTIONS
1. APPLICATION FOR A COMMUNITY CARE FACILITY LICENSE (LIC 200)
All items are filled out completely.
All applicants must sign the application.
The application should contain original signatures. The licensing agency will not accept photocopied signatures on
this form.
If the application indicates that the applicant previously held a license for a facility, the licensing agency will compare
the Applicant Information Form (LIC 215), and verify that the applicant is not subject to disciplinary action.
All persons signing the application must be authorized by the board resolution and the board resolution must be
submitted with this form.
2. ORIENTATION CERTIFICATE
Proof of attendance to the Community Care Licensing STRTP Orientation MUST be submitted with an application.
3. COUNTY LETTER OF RECOMMENDATION
Prior to submitting an application, a STRTP shall obtain at least one letter of recommendation in support of its
program from a county placing agency.
The applicant must submit a list of all county placing agencies they sent their program statement to.
If the applicant submits their application without a letter of recommendation in support of its program, the
department shall cease review of the application.
4. APPLICANT INFORMATION (LIC 215)
The form is completed for the person designated to act for the board, the signatory and the administrator.
If the applicant previously held a license, held a beneficial ownership of 10 percent or more or was an administrator,
general partner, corporate officer, or director of a licensed facility, the licensing agency will research to determine if
the applicant is subject to disciplinary action.
The form must contain original signatures. The licensing agency will not accept photocopied signatures on this
form. Reference statements must be current and should not be from relatives.
This form will be used as necessary to verify qualifications when an applicant also intends to be the
Administrator/Director.
5. DESIGNATION OF FACILITY RESPONSIBILITY (LIC 308)
At least one individual must be designated as the authorized person of the STRTP to act in the licensee’s absence.
A LICENSEE CANNOT DESIGNATE HIM OR HERSELF. More than one staff person may be designated on
a form.
A board resolution must authorize the delegation and be submitted with this form.
The form must contain the original signatures of the applicants/licensees. The licensing agency will not accept
photocopied signatures on this form.
6. AFFIDAVIT REGARDING CLIENT CASH RESOURCES (LIC 400)
Make sure the form is completed and the appropriate box is checked.
Make sure a bond is obtained if needed.
The form must contain the original signatures of the applicants/licensees. The licensing agency will not accept
photocopied signatures on this form.
LIC 281E (1/17) (PUBLIC - OPTIONAL)
PAGE 3 OF 8
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
7. SURETY BOND (LIC 402)
Make sure the bonding agency uses the language found on the LIC 402, if the form itself is not used. The State of
California must be identified as the beneficiary and there must be an effective date and expiration date.
Compare the LIC 402 to ensure that the bond is in the amount indicated on the LIC 400.
Below are examples of situations when a bond is needed. (Because a licensee or facility employee is handling
client cash resources).
The licensee/facility employee cashes client’s check at the bank and returns the money to the client. In this
situation, the licensee/facility employee has handled the client’s money.
The licensee/facility employee keeps client money in a safe place, including a bank or other financial
institution, and controls its distribution (i.e. hands out money).
The original bond with original seal and signatures must be submitted. The form must contain the original
signatures of the applicants/licensees. The licensing agency will not accept photocopied signatures on this form.
8. MONTHLY OPERATING STATEMENT (LIC 401)
Instructions are found on the reverse side of the form.
Make sure the number of clients corresponds with the requested capacity.
Other facility income must be clear and documented.
All facility operating costs must be indicated and reasonable (i.e. salaries shown as at least minimum wage).
Approximately 25 percent of the salaries should normally be added for fringe benefits. If fringe benefits are
applicable, the application should so state and explain why.
Make sure rent amount corresponds with the lease/rental agreement/mortgage payment.
If the applicant is the licensee of another facility, a separate LIC 401 must also be submitted for each licensed
facility. For facilities in operation, this information must reflect the actual operating budget, not an estimate. At the
top of the LIC 401, the applicant is to indicate whether the information contained on the form is estimated or actual.
Make sure the form contains both the name of the preparer and the original signature of the applicant(s).
The licensing agency will not accept photocopies of signatures on this form.
LIC 281E (1/17) (PUBLIC - OPTIONAL)
PAGE 4 OF 8
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
THE FOLLOWING FINANCIAL FORMS ARE NECESSARY IN ORDER TO CAPTURE THE OVERALL FINANCIAL
STATUS OF THE APPLICANT AND TO DETERMINE IF THE APPLICANT HAS SUFFICIENT FINANCIAL
RESOURCES TO OPERATE THE FACILITY (I.E. MEET EXPENSES). THESE FORMS AND A CREDIT REPORT
WILL BE REVIEWED IN CONJUNCTION WITH ONE ANOTHER.
9. SUPPLEMENTAL FINANCIAL INFORMATION (LIC 401A)
Instructions are found on the reverse side of the form.
Part I is to reflect all other incomes and expenses, excluding facility income.
Part I is to only be completed by sole proprietors and each general partner.
Part II is to be completed by all applicants.
Make sure the form contains both the name of the preparer and the original signature of the applicant(s).
The licensing agency will not accept photocopies of signatures on this form.
10. BALANCE SHEET (LIC 403)
STOP: The LIC 403A should be completed before filling out this form.
Instructions are found on the reverse side of the form.
The information provided is to reflect assets and liabilities concerning all activities of the owners, not just those
related to the operation of the facility.
Figures must be realistic.
Life insurance amount must be the cash value or surrender value, not “face value,” (normally the amount to be
paid upon death).
The cost of the real estate should be indicated, not the appraised value.
On-site furnishings and equipment listed should indicate the market value.
Only cash and cash equivalents should be considered for meeting the three month start-up funds requirement.
Cash equivalents are those assets which are readily converted to cash in one week or less.
All information on the LIC 403A corresponds with information on LIC 403.
Make sure the form contains both the name of the preparer and the original signature of the applicant(s).
The licensing agency will not accept photocopies of signatures on this form.
11. BALANCE SHEET SUPPLEMENTAL SCHEDULE (LIC 403A)
This is a detailed balance sheet to be completed prior to completing the LIC 403.
Instructions are found on the reverse side of the form.
Cash in the bank will be verified with the use of the LIC 404.
The licensing agency verifies liabilities by obtaining a credit report on the applicant.
Make sure the form contains both the name of the preparer and the original signature of the applicant(s).
The licensing agency will not accept photocopies of signatures on this form.
12. FINANCIAL INFORMATION RELEASE AND VERIFICATION (LIC 404)
This information is used to verify approximately three months of operating funds.
If readily accessible, a verifiable line of credit from a reputable financial institution (i.e. a bank, savings and loan,
credit union or major credit card) is acceptable for use as start-up funds. The credit check process requires certain
past debts be brought current.
Start-up funds should not be consumed on renovation or repair work to the facility.
The licensing agency will send this form to the financial institution. The verification must be sent by the financial
institution directly to the licensing agency. THE LICENSEE CANNOT HAND CARRY IT.
One form or set of forms is required for each bank.
Bank accounts must be in the applicant’s name.
The licensing agency will not accept photocopied signatures on this form.
LIC 281E (1/17) (PUBLIC - OPTIONAL)
PAGE 5 OF 8
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