Form Sr 2g - Group Home Program Audit Report

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STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
GROUP HOME PROGRAM AUDIT REPORT (SR 2G)
DATE(S) OF PROGRAM AUDIT
AUDITED PERIOD
PROVIDER NAME:
PROGRAM NUMBER
PROGRAM NAME:
MO
YR
MO
YR
(11)
(1)
(12)
CHILD CARE & SUPERVISION
SOCIAL WORK ACTIVITIES
MENTAL HEALTH ACTIVITIES
90% OF
AUDITED
AUDITED POINTS PER PROGRAM
LICENSED
MONTH/
(10)
(3)
(4)
(5)
(2)
(6)
(7)
(8)
(9)
PER MONTH
AUDITED
CAPACITY
POINTS
YEAR
WEIGHTED
POINTS
VERIFIED
POINTS
(COL. 4) + (COL. 7)
VERIFIED
WEIGHTED
VERIFIED
WEIGHTED
(COL. 9) ÷ (COL. 1)
(COL. 3) ÷ (COL. 1)
)
RCL
(Minimum is 5.4)
HOURS
HOURS
HOURS
HOURS
(COL. 6) ÷ (COL. 1)
HOURS
HOURS
+ (COL. 10
MAXIMUM = 30
1.
JAN
2.
FEB
3.
MAR
4.
APR
5.
MAY
6.
JUN
7.
JUL
8.
AUG
9.
SEPT
10. OCT
11. NOV
12. DEC
13. TOTALS
14. AVERAGE
If you disagree with the
RCL/rate set by the
Auditor:_____________________________________________________Date:__________________
Overpayment
Yes
No
Department, an appeal
may be filed within
Auditor:_________________________________________________________Revision Date:_______
*
Amount Due $___________________
60 days of the receipt
of the "FINAL" program
Audited RCL:___________________________________________
audit report.
Audited Rate:___________________________________________
SR 2G (12/02)

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