Form Soc 171 - Transitional Housing Program-Plus-Foster Care (Thp-Plus-Fc) Application - Approval/denial/denial Pending Checklist Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TRANSITIONAL HOUSING PROGRAM-PLUS-FOSTER CARE APPLICATION -
APPROVAL/DENIAL/DENIAL PENDING CHECKLIST
4. PROVIDER PLAN OF OPERATION, ONSITE INSPECTION OF THE LIVING SITE
Applicant confirms that it will use the on-site inspection checklist (SOC 174) of the living site, including the building
I I
and grounds that will ensure the health and safety of non-minor dependents living in the placement.
5. YOUNG ADULT'S PERSONAL RIGHTS
I I
The provider agrees to respect the personal rights of the non-minor dependent in foster care as outlined in
Welfare and Institutions Code section 16001.9.
6. COMPLETION OF ORIENTATION/TRAINING
The provider has obtained a copy of Provider Approval Standards and completed the county orientation.
I I
I certify that the above named applicant meets the requirements as a provider of THP-Plus-FC services as outlined in the
program’s Approval Standards.
___________________________________________________________
REVIEWER’S SIGNATURE
(DATE)
The applicant has not completed the application process as required. The following is incomplete:
___________________________________________________________
REVIEWER’S SIGNATURE
(DATE)
The applicant has resubmitted the application and has included the information that was incomplete. The applicant is
therefore approved to provide THP-Plus-FC services.
___________________________________________________________
REVIEWER’S SIGNATURE
(DATE)
The provider has not corrected the incomplete application and therefore DOES NOT meet the requirements of the THP-
Plus-FC approval standards.
___________________________________________________________
REVIEWER’S SIGNATURE
(DATE)
SOC 171 (5/12)
PAGE 2 OF 3

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