Form Soc 177 - Facility Evaluation Report - Transitional Housing Program-Plus-Foster Care Facility Page 2

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FACILITY EVALUATION REPORT – This report is a record for the facility and the approving agency. This report is
available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries
concerning the location, maintenance and contents of these reports may be directed to the evaluator or office whose
address and telephone number are listed on the front.
DEFICIENCIES – Deficiencies are noncompliances with approval standards. Applicants/Providers must be notified in
writing of all approving deficiencies. Deficiencies may be identified on the left side of this form with a reference to
identify the section of the approval standards upon which the deficiency is based.
CORRECTIVE ACTION PLAN
– The approving agency will establish the time for correction. In order to set the time,
the approving agency must take into consideration the seriousness of the deficiency, the number of clients/residents
involved and the availability of equipment and personnel. Applicants/Providers are requested to provide a specific plan
for each deficiency on the right side of the form across from each deficiency. The more specific the plan, the less
chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/provider who
encounters problems beyond his/her control in completing the corrections within the specified time frame may request
and may be granted an extension of the correction due date by the approving agency.
CORRECTION NOTIFICATION – The applicant/provider is responsible for completing all corrections and promptly
notifying the approving agency of corrections. Applicants/Providers are advised to keep a dated copy of any letters sent
to the approving agency concerning corrections, or if corrections are telephoned to the approving agency, the date,
person contacted, and information given.
GRIEVANCE RIGHTS – The applicant/provider has a right without prejudice to discuss any disagreement in this report
with the approving agency concerning the proper application of approval standards.
AGENCY REVIEW – The approving agency review of a grievance appeal may be conducted based upon information
provided in writing by the applicant/provider. The applicant/provider may request an office interview to provide
additional information. The applicant/licensee will be notified promptly in writing of the results of the agency review.
SOC 177 (5/12)
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