Form Sr 2h - Group Home Program Current Month Audit Report
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2STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
GROUP HOME PROGRAM CURRENT MONTH AUDIT REPORT (SR 2H)
PROVIDER NAME:
PROGRAM NUMBER:
CURRENT MONTH AUDIT:
(1)
(12)
(11)
CHILD CARE & SUPERVISION
SOCIAL WORK ACTIVITIES
MENTAL HEALTH ACTIVITIES
90% OF
AUDITED POINTS PER
AUDITED
LICENSED
PROGRAM
MONTH/
(4)
(2)
(5)
(10)
(3)
(6)
(7)
(8)
(9)
PER MONTH
CAPACITY
POINTS
VERIFIED
POINTS
YEAR
VERIFIED
POINTS
WEIGHTED
VERIFIED
WEIGHTED
WEIGHTED
(COL. 4) + (COL. 7)
AUDITED RCL
(COL. 3) ÷ (COL. 1)
(COL. 9) ÷ (COL. 1)
(Minimum is 5.4)
HOURS
HOURS
HOURS
(COL. 6) ÷ (COL. 1)
HOURS
HOURS
HOURS
+ (COL. 10)
MAXIMUM = 30
TO TALS:
Audited RCL:
Auditor:
Date:
Paid RCL:
Audited Rate:
Auditor:
Paid Rate:
SR 2H (12/02)
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