Form Fcr 16 - Group Home/short Term Residential Therapeutic Program (Strtp) Shelter Costs Declaration And Survey

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State of California – Health and Human Services Agency
California Department of Social Services
GROUP HOME/SHORT TERM RESIDENTIAL THERAPEUTIC PROGRAM
(STRTP) SHELTER COSTS DECLARATION AND SURVEY
Licensee/Non-Profit Organization (NPO) Name: _________________________________________________
Program Number: (new provider leave blank) ___________________________________________________
Mailing Address: __________________________________________________________________________
E-Mail Address: __________________________________________________________________________
Contact Person: __________________________________________________________________________
Telephone Number: _______________________________________________________________________
PART I
PLEASE USE CURRENT DATA TO RESPOND TO THIS SURVEY
1. _____
Total number of all facilities currently licensed and/or pending licensure under your NPO name
for this Group Home/STRTP. (sum of line 2 to 3c)
2. _____
Enter the number of facilities owned by the NPO for which the NPO has clear title
or has a mortgage/deed of trust.
3a. _____
Enter the number of facilities for this program for which the NPO has a contractual
(rental or lease) agreement from a Board Member, Director, Administrator or employee of
the organization.
3b. _____
Enter the number of facilities for this program for which the NPO has a contractual
(rental or lease) agreement from a lessor who is connected to a Board Member, Director,
Administrator or employee of the organization, not otherwise identified in 3a.
Enter the number of facilities for this program for which the NPO has a contractual (rental or
3c. _____
lease) agreement from an individual or entity who is not affiliated with the NPO.
4. _____
Enter the number of leases identified above that include any non-shelter use such as
commercial or home office space. If any, describe below:
FCR 16 (10/17)
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