Form Lic 281e - Application And Supporting Documentation Checklist - Short-Term Residential Therapeutic Program Page 2
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8CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
INTRODUCTION
These instructions are intended to help you file an application for a Short-Term Residential Therapeutic Program (STRTP)
license. The above checklist guides an applicant in filing the application. Before a license can be issued, the licensing agency
must review the Application and Supporting Documentation submitted to verify you meet the minimum requirements for
the license.
The initial application fee plus all Application and Supporting Documentation, including the Plan of Operation and Program
Statement must be completed and sent to the licensing agency as a packet. The application fee is non-refundable. Your
application cannot be started until all the forms are filed with the licensing agency. The STRTP shall submit a copy of its
program statement to all county placing agencies with which placements are coordinated or services provided for, including the
county in which the facility is located, for optional review when the STRTP updates its plan of operation/program statement.
Once the letter of recommendation(s) has been received, the initial application (LIC 200) must be filled out with the attached
Letter of recommendation(s), and submitted to the licensing agency for review.
Submit two complete copies of all Application and Supporting Documentation in the same sequence as they are listed above,
tabbed and in binders. If the forms are incomplete, the licensing agency may return the packet to you. To prevent delays, be
sure that you have all the necessary information completed, properly signed, with original signatures, and dated. Make a
photocopy of your Application and Supporting Documentation before you give it to the licensing agency.
CREDIT REPORT - The purpose of a consumer credit report is to report your credit history and whether or not you repay loans
on time for the things you buy.
Your rights of privacy are protected by law. The Department of Social Services obtains credit reports per Section 604 of the Fair
Credit Reporting Act:
“A consumer reporting agency may furnish a consumer report under the following circumstances and no other :...(3) To a person
which it has reason to believe… (D) intends to use the information in connection with a determination of the consumer’s
eligibility for a license or other benefit granted by a governmental instrumentality required by law to consider an applicant’s
financial responsibility or status:…”
Your consumer credit report is maintained in the confidential section of your facility file which is maintained in your local
regional office.
REGULATIONS - The regulations that govern STRTPs covered by these application instructions are under California Code of
Regulations, Title 22, Division 6 and interim licensing standards, Chapter 7.5 Short-Term Residential Therapeutic Program,
Articles 1-10.
Copies of the regulations and amendments can be downloaded from
LIC 281E (1/17) (PUBLIC - OPTIONAL)
PAGE 2 of 8
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