Form Soc 170 - Application To Become A Transitional Housing Program (Thp)-Plus-Foster Care Provider
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICATION TO BECOME
A TRANSITIONAL HOUSING PROGRAM (THP)-PLUS-FOSTER CARE PROVIDER
I________________________________ am applying with
Applicant’s Name
_____________________________________________
County(ies) Name
to become a THP-Plus-Foster Care provider. As part of the application process, I am providing the following information:
1. APPLICATION
I am attaching the following:
I I
Completed Application.
I I
Application signed by Executive Director, Chief Executive Officer, or a member of the Board of Directors.
I I
Articles of Incorporation are attached.
I I
The following disclosures are attached:
1
Board members, Executive Director has had prior or current participation on another non-profit’s Board of
Directors;
2. Member of Board of Directors or Executive Director holds beneficial ownership of ten percent or more of
THP-Plus-FC facility or other licensed facility;
3.
Information about revocation of approval or other disciplinary action that was or is currently being taken
against the applicant, a member of the Board of Directors, an officer of the non-profit or applicant’s 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 including background and Child Abuse Central Index (CACI) clearances, employment history,
educational and character references obtained within the last _______ years.
I I
Written statement attached describing how the Board of Directors performs duties.
1. Include other duties that are outside the scope of the Board of Directors.
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An attached Plan of Operation.
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Copy of the most recent A-133 audit report.
Written verification of availability of three months of operating capital and witnessed by the Executive Director or
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delegated Member of the Board of Directors.
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A Secondary County Letter of Support indicating that the applicant will provide services in its county
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If approved, the applicant agrees to cooperate with investigations conducted by the lead/secondary county.
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
I I
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:
I I
Employee’s employment history and educational background documentation;
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Medical screening requirements;
I I
Employee duty statements;
I I
Volunteer records;
Criminal record clearance and CACI check results;
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Record of background clearance exemption requests;
I I
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System of record retention of non-minor dependent (NMD) case files;
1. Maintain a List of funds and personal effects being held at the request of the NMD.
SOC 170 (5/12)
PAGE 1 OF 2
(ORIGINAL KEPT WITH FILE, COPY SENT TO APPLICANT)
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