Form Soc 171 - Transitional Housing Program-Plus-Foster Care (Thp-Plus-Fc) Application - Approval/denial/denial Pending Checklist
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TRANSITIONAL HOUSING PROGRAM-PLUS-FOSTER CARE (THP-PLUS-FC) APPLICATION -
APPROVAL/DENIAL/DENIAL PENDING CHECKLIST
Pursuant to the provisions outlined in the Provider Approval Standards, the following has been assessed to approve/deny
application requesting to provide THP-Plus-FC services:
1. APPLICATION
The following has been received:
Completed Application.
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Application signed by Executive Director, Chief Executive Officer, or Board of Director Member.
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Articles of Incorporation is attached.
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Circle that any one or all disclosures are attached to application regarding:
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Prior or current participation on another non-profit’s Board of Directors;
2. Any Board of Directors or Executive Director that holds beneficial ownership of ten percent or more of
THP-Plus-FC facility or other licensed facility;
3.
Any revocation of approval or other disciplinary action that was or is currently being taken against the
applicant, a member of the Board of Directors, a Corporate Officer, or employee;
4. A copy of a Board of Director’s Minutes stating that the applicant is authorized to apply for approval to
be a THP-Plus-FC provider;
5. Information about the applicant and/or employees including criminal background and Child Abuse
Central Index (CACI) clearances, employment history, education history, and character references
obtained within the last _______ years.
Written statement attached describing how the Board-of-Directors performs duties
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1. Include other duties that are outside the scope of the Board of Directors
An attached Plan of Operation.
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Copy of the most recent A-133 audit report.
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Verification, in writing, of availability of three months of operating capital.
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A Secondary County Letter of Support indicating that the applicant will provide services in its county.
If approved, the applicant agrees to cooperate with investigations conducted by the lead/secondary county
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approving or placing agencies; agrees to enter into corrective action plans pertaining to violations of approval
standards; and agrees to come into compliance with approval standards in order to remain as a THP-Plus-FC
provider.
2. CRIMINAL RECORD/CACI CLEARANCES
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Criminal Record and CACI records per Welfare and Institutions Code section 11403.25 have been obtained for the
provider and staff working with non-minor participants, including exemptions if necessary.
3. INSPECTION OF PROVIDER’S FACILITY
After inspecting provider’s facility, it was noted that the provider had:
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Employees employment history and educational background documentation.
Medical screening requirements.
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Employee duty statements.
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Volunteer records.
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Criminal record clearance and CACI check results.
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Record of background clearance exemption requests.
System of record retention of non-minor dependent case files.
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1. Maintain a List of funds and personal effects being held at the request of the non-minor dependent.
SOC 171 (5/12)
PAGE 1 OF 3
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