Form LIC9106A "Plan of Operation/Program Statement - Short-Term Residential Therapeutic Program" - California

What Is Form LIC9106A?

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 March 1, 2021;
  • 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 LIC9106A 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 LIC9106A "Plan of Operation/Program Statement - Short-Term Residential Therapeutic Program" - California

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State of California - Health and Human Services Agency
California Department of Social Services
SHORT-TERM RESIDENTIAL
THERAPEUTIC PROGRAM
Plan of Operation
&
Program Statement
Version 3.1
Released: 3/2021
LIC 9106A (3/21) - Optional Use - Public
State of California - Health and Human Services Agency
California Department of Social Services
SHORT-TERM RESIDENTIAL
THERAPEUTIC PROGRAM
Plan of Operation
&
Program Statement
Version 3.1
Released: 3/2021
LIC 9106A (3/21) - Optional Use - Public
State of California - Health and Human Services Agency
California Department of Social Services
SHORT-TERM RESIDENTIAL THERAPEUTIC PROGRAM
Effective January 1, 2017,
Assembly Bill (AB) 403 (Chapter 773, Statutes of 2015)
established a
new community care facility category called Short-Term Residential Therapeutic Program (STRTP).
An STRTP is a residential facility operated by a public agency or private organization that provides
an integrated program of specialized and intensive care and supervision, services and supports,
treatment, and short-term 24-hour care and supervision to children and non-minor dependents. The
care and supervision provided by an STRTP shall be non-medical, except as otherwise permitted by
law. Private STRTPs shall be organized and operated on a non-profit basis.
LICENSURE
An STRTP is licensed by the Community Care Licensing Division (CCLD) of the California
Department of Social Services (CDSS) pursuant to Health and Safety Code (HSC) section 1562.01
and other applicable laws. The STRTP
Interim Licensing Standards
(ILS) constitute the written
instructions authorized by AB 403 governing the licensure of STRTPs.
Prior to filing a licensing application, a prospective licensee must attend an STRTP orientation. In
order to be considered for licensure, a prospective licensee must submit a completed application
and all required supporting documentation, including this Plan of Operation and Program
Statement, and application fee. For assistance filling out the application and other licensing forms,
please see
LIC 281E
Application and Supporting Documentation Checklist.
ACRONYMS/ABBREVIATIONS
• CCLD:
Community Care Licensing Division (CDSS)
• CCR:
California Code of Regulations
• CDSS:
California Department of Social Services
• CFT:
Child and Family Team
• FCARB: Foster Care Audits & Rates Branch (CDSS)
• GC:
Government Code
• HSC:
Health & Safety Code
• LIC:
Licensing Forms (CCLD)
• MPP:
Manual of Policies & Procedures
• NMD:
Nonminor Dependent
• STRTP: Short-Term Residential Therapeutic Program
• WIC:
Welfare & Institutions Code
LIC 9106A (3/21) - Optional Use - Public
Page II
State of California - Health and Human Services Agency
California Department of Social Services
SHORT-TERM RESIDENTIAL THERAPEUTIC PROGRAM
General Instructions: This document is intended to provide a prospective licensee or licensee
with general guidance on how to prepare, update, and submit the Plan of Operation and Program
Statement. This document may not include all statutory, regulatory, or interim licensing standard
requirements. An applicant / licensee must meet all licensing standards even if not identified in this
document.
A prospective licensee or licensee shall prepare and maintain on file a current, written, definitive
plan of operation and program statement that meets all standards, is sufficient to ensure that the
facility will operate in compliance with applicable laws, and demonstrates an understanding of
and ability to provide an integrated program that is culturally relevant, trauma-informed, and age
and developmentally appropriate for the population(s) to be served. An STRTP shall operate in
accordance with the terms specified in its plan of operation and program statement.
INITIAL SUBMISSION OF PLAN OF OPERATION AND PROGRAM STATEMENT
Step One:
Prepare a detailed, written plan of operation and program statement.
Step Two:
Submit one copy of the plan of operation and program statement to all county placing
agencies from which the applicant anticipates receiving placements, including the
county in which the facility is located, to obtain at least one letter of recommendation in
support of the facility’s program from a county placing agency.
Step Three: Submit two copies of the plan of operation and program statement to your local CCL
Regional Office or local unit as part of your application package.
UPDATING/REVISING PLAN OF OPERATION AND PROGRAM STATEMENT
An STRTP shall immediately update its plan of operation and/or program statement when it makes
changes to its operation or program as required by ILS §§ 87022 and 87022.1. Updates/revisions
shall be submitted for licensing agency approval.
Step One:
Update/revise plan of operation and program statement to reflect changes to your
facility’s operation or programs. Note: It is only necessary to submit the documents/
pages that have been updated or revised, along with a new table of contents and cover
sheet that indicates the revision date for each section being updated or revised.
Step Two:
Submit a copy of your updated/revised plan of operation and/or program statement to
all county agencies from which the facility accepts placements, including the county
in which the facility is located, for optional review. Include a statement of declaration
which lists all county placing agencies your plan of operation and/or program statement
was submitted to for optional review.
Step Three: Submit two copies of your updated/revised plan of operation and program statement to
your local CCL Regional office or local unit.
FORMATTING
Type or print clearly
Prepare and compile the information and documentation as required
Use the table of contents contained herein
Use number/letter tabs or sheets to separate sections within each table of content
Place a cover sheet in front of each section of the binder
Place all materials, in the order shown, in a three ring binder, divided by section
Keep a copy for your records
LIC 9106A (3/21) - Optional Use - Public
Page III
State of California - Health and Human Services Agency
California Department of Social Services
PLAN OF OPERATION/PROGRAM STATEMENT
Short-Term Residential Therapeutic Program
FACILITY IDENTIFICATION
Applicant/Licensee Name:
Program Name (If Any) Or Name Commonly Known As Or Different Than Above:
Mailing Address:
Applicant/Licensee
Facility Location(s)
(Provide in the table below the name and address of the main administrative office operating the Short-Term
Residential Therapeutic Program. Provide the address of each sub-office.)
Facility
Address (Street Name,
Facility Name
Licensed Capacity
License Number
City, Zip, Telephone Number)
Attach additional sheet, if necessary.
Contact Person’s Name:
Title:
Phone Number:
DOES THIS AGENCY OPERATE ANY OTHER FACILITIES/BUSINESSES OTHER THAN A
SHORT-TERM RESIDENTIAL THERAPEUTIC PROGRAM?
(Examples of other facilities/businesses are group home(s), adoption agency, adult care, thrift shop, health
care facility, etc.)
n YES n NO if yes, specify type of facilities/businesses:
LIC 9106A (3/21) - Optional Use - Public
State of California - Health and Human Services Agency
California Department of Social Services
PLAN OF OPERATION/PROGRAM STATEMENT
Short-Term Residential Therapeutic Program
Applicant/Licensee Name:
Program Number:
REASON FOR SUBMITTING PLAN OF OPERATION/PROGRAM STATEMENT
Check the boxes below that best describe the reason(s) a new or updated Plan of Operation/
Program Statement is being submitted. At least one box must be checked.
Initial License Application (New applicant)
License Change
Location
Change in facility category
Administrative Operation/Organization
Sale or Transfer of Majority of Stock
Separation from Parent Nonprofit Corporation
Merger with Another/Different Nonprofit Corporation
Other Change(s):
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Adding New Program Component(s)
Population
Services and Supports
Other Change(s):
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Changing an Existing Program Component(s)
Population
Services and Support
Other Change(s):
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
LIC 9106A (3/21) - Optional Use - Public
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