Form Soc 177 - Facility Evaluation Report - Transitional Housing Program-Plus-Foster Care Facility

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FACILITY EVALUATION REPORT -
REFER TO
TRANSITIONAL HOUSING PROGRAM-PLUS-FOSTER CARE FACILITY
See next page for explanation of form.
FACILITY NAME
DIRECTOR
FACILITY NUMBER
FACILITY TYPE
ADDRESS
TELEPHONE
DATE
(
)
TIME VISIT BEGAN
I I
I I
I I
I I
TYPE OF VISIT:
OFFICE
FOLLOW-UP
MET WITH
ANNOUNCED
I I
I I
I I
PRE-APPROVAL
ANNUAL
UNANNOUNCED
TIME COMPLETED
DEFICIENCY INFORMATION FOR THIS PAGE:
I I
I I
I I
Type A
Type B
No Deficiency Cited
COMMENTS/DEFICIENCIES
CORRECTIVE ACTION PLAN
DUE DATE
Failure to correct the above cited deficiency(ies), on or before the Corrective Action Plan due date, may result in decertification of
site, revocation of provider approval, or denial of application.
EVALUATOR SIGNATURE
TELEPHONE
DATE
I understand my appeal rights as explained
on the next page of this form.
(
)
NAME OF SUPERVISOR
TELEPHONE
FACILITY REPRESENTATIVE SIGNATURE
DATE
(
)
AGENCY COPY
PAGE ______ OF ______ PAGES
SOC 177 (5/12)

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