Form CCL.039 "Request for Exception to Provide Foster Care" - Kansas

This version of the form is not currently in use and is provided for reference only.
Download this version of Form CCL.039 for the current year.

What Is Form CCL.039?

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

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • 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 printable version of Form CCL.039 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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Download Form CCL.039 "Request for Exception to Provide Foster Care" - Kansas

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CCL. 039
Kansas Department of Health and Environment
Rev. 3/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone 785-296-1270 Fax 785-559-4244
Website: www.kdheks.gov/kidsnet
REQUEST FOR EXCEPTION TO PROVIDE FOSTER CARE
Name of Facility Exactly as stated on the License
License Number
Phone
Street Address of the Facility
City
Zip Code
Sponsoring Child Placing Agency (CPA)
CPA Licensing Worker Name and Phone Number
Please complete all of the following information with your Sponsoring Child Placing Agency Worker and return
to your Child Care Surveyor. DO NOT send this request directly to KDHE. Incomplete requests will increase the time
required to review the exception request. NOTE: A new exception request must be submitted if the Child Placing Agency
Sponsorship changes or if the terms of an exception changes.
THIS SECTION MUST BE COMPLETED BY THE CHILD CARE PROVIDER(S):
I/We request a _____ new OR _____ renewed exception to foster because (please check the appropriate response):
A child(ren) or child(ren)’s family is known to our family and is in need of a foster home.
___
___
I/We have been identified as a possible adoptive resource for a child(ren) in foster care.
___
A child(ren) enrolled in the facility is in need of a foster home.
___
I/We only want to provide respite care per K.A.R. 28-4-812. (This is noted as a condition on the exception.)
I/We attest to the following (please answer Y for Yes or N for No):
___
I/We have been a licensed child care facility for a year or longer.
___
I/We have maintained compliance with KDHE regulations that apply to the child care license.
(An Administrative review will be conducted by KDHE to verify compliance history.)
___
I/We have notified parents of all children enrolled in the facility of my/our desire to provide foster care.
___
I/We understand an exception to foster cannot cause the facility to exceed maximum license capacity.
I/We attest, under the penalty of perjury, that the information submitted on this form is true and correct.
Provider(s) Signature(s)
Date
THIS SECTION MUST BE COMPLETED BY THE CPA LICENSING WORKER:
I attest that (please answer Y for Yes or N for No):
___
I have verified that the providers are PS-MAPP certified. Both the PS-MAPP evaluator and sponsoring CPA
Licensing Worker have given a recommendation that the family provide foster care.
___
I have clearly stated why the exception is necessary and the relationship, if any, of the child(ren) to the
provider(s).
___
I have thoroughly discussed the potential impact that providing two types of care may have on children enrolled
in the facility, the foster children placed in the home, and the provider(s) own family. I have provided guidance
for requesting an exception to provide foster care to the provider(s).
___
I have completed an assessment of the family that includes (please attach the assessment with any addendums
and the necessary documentation if respite care is being requested):
1. The Recommendations for Use which excludes placement of children who exhibit behaviors that pose a
potential risk of harm to children in out of home child care.
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CCL. 039
Kansas Department of Health and Environment
Rev. 3/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone 785-296-1270 Fax 785-559-4244
Website: www.kdheks.gov/kidsnet
REQUEST FOR EXCEPTION TO PROVIDE FOSTER CARE
Name of Facility Exactly as stated on the License
License Number
Phone
Street Address of the Facility
City
Zip Code
Sponsoring Child Placing Agency (CPA)
CPA Licensing Worker Name and Phone Number
Please complete all of the following information with your Sponsoring Child Placing Agency Worker and return
to your Child Care Surveyor. DO NOT send this request directly to KDHE. Incomplete requests will increase the time
required to review the exception request. NOTE: A new exception request must be submitted if the Child Placing Agency
Sponsorship changes or if the terms of an exception changes.
THIS SECTION MUST BE COMPLETED BY THE CHILD CARE PROVIDER(S):
I/We request a _____ new OR _____ renewed exception to foster because (please check the appropriate response):
A child(ren) or child(ren)’s family is known to our family and is in need of a foster home.
___
___
I/We have been identified as a possible adoptive resource for a child(ren) in foster care.
___
A child(ren) enrolled in the facility is in need of a foster home.
___
I/We only want to provide respite care per K.A.R. 28-4-812. (This is noted as a condition on the exception.)
I/We attest to the following (please answer Y for Yes or N for No):
___
I/We have been a licensed child care facility for a year or longer.
___
I/We have maintained compliance with KDHE regulations that apply to the child care license.
(An Administrative review will be conducted by KDHE to verify compliance history.)
___
I/We have notified parents of all children enrolled in the facility of my/our desire to provide foster care.
___
I/We understand an exception to foster cannot cause the facility to exceed maximum license capacity.
I/We attest, under the penalty of perjury, that the information submitted on this form is true and correct.
Provider(s) Signature(s)
Date
THIS SECTION MUST BE COMPLETED BY THE CPA LICENSING WORKER:
I attest that (please answer Y for Yes or N for No):
___
I have verified that the providers are PS-MAPP certified. Both the PS-MAPP evaluator and sponsoring CPA
Licensing Worker have given a recommendation that the family provide foster care.
___
I have clearly stated why the exception is necessary and the relationship, if any, of the child(ren) to the
provider(s).
___
I have thoroughly discussed the potential impact that providing two types of care may have on children enrolled
in the facility, the foster children placed in the home, and the provider(s) own family. I have provided guidance
for requesting an exception to provide foster care to the provider(s).
___
I have completed an assessment of the family that includes (please attach the assessment with any addendums
and the necessary documentation if respite care is being requested):
1. The Recommendations for Use which excludes placement of children who exhibit behaviors that pose a
potential risk of harm to children in out of home child care.
- 1 -
2. Verification the provider(s) acknowledge(s) that any foster child(ren) to be placed in the home over the age
of 10 is/are required to be submitted to KDHE for a background check according to K.A.R. 28-4-125 prior to
placement. Prohibiting offenses pursuant to K.S.A. 65-516 will prevent the approval of an exception to
foster.
3. A plan that addresses who will be available to provide substitute care to all children in the home in
accordance with both day care home and family foster home regulations in the event that an emergency
situation arises with either a day care child or a child in foster care.
4. A recommendation that the family has the ability and necessary resources to provide quality care for all
children while maintaining stability within their own family.
I attest, under the penalty of perjury, that the information submitted on this form is true and correct.
Sponsoring CPA Licensing Worker Signature
Date
THIS SECTION MUST BE COMPLETED BY THE CHILD CARE LICENSING SURVEYOR:
Recommendation:
___
Recommend Approval
___
Do Not Recommend Approval
Comments (compliance history and observations made in the home; attach additional page if necessary):
Child Care Surveyor Signature
Date
THIS SECTION MUST BE COMPLETED BY KDHE ADMINISTRATIVE STAFF:
Request INCOMPLETE:
___
Additional Information was requested from the Sponsoring CPA.
___
The exception request was submitted without the child care surveyor recommendation.
___
There was no assessment attached.
___
Other (describe):
Request NOT GRANTED: An Administrative review of this request was conducted on _______________. Based on the
review and supporting documentation, the request is not granted in the best interest of children for the following reason(s):
Request GRANTED: An Administrative review of this request was conducted on _______________. Based on the review
and supporting documentation, the request is granted in the best interest of children.
Effective Date: ______________________
Expiration Date: ______________________
Additional condition(s) to be noted on the exception:
KDHE Authorized Child Care and Foster Care Signature(s)
Date
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