Form Fc 30 - Group Home Extension Request For The Rate Classification Level (Rcl) Rate

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State of California – Health and Human Services Agency
California Department of Social Services
GROUP HOME EXTENSION REQUEST
FOR THE RATE CLASSIFICATION LEVEL (RCL) RATE
SECTION A
(Sections A-C Must Be Completed For Approval)
This form is to request a RCL extension (pursuant to WIC section 11462.04) on behalf of a group home
provider and must be signed by a child welfare director, chief probation officer, or designee and sent to the
Foster Care Rates Bureau (FCRB).
Name of County: _______________________________
Check One:
Host
Placing County
Non-Profit Corporation name (group home provider): _____________________________________________
Corporation’s program number given by FCRB: _________________________________________________
Corporation’s headquarter address: ___________________________________________________________
Street
State
Zip Code
Facility address: __________________________________________________________________________
Street
State
Zip Code
Facility License Number (for which this request is being submitted): _________________________________
Extension to the RCL Rate is requested for:
3 months
6 months
___ months (Additional engagement with the county required for requests longer than 6 months.)
SECTION B
This RCL extension request is based on the following criteria. Check the appropriate response below:
1.
The group home is in the process of converting to a STRTP.
a.
Program Statement not yet submitted for county review. _______________________
Expected Submission Date
b.
Program Statement submitted to county. _______________________
Date
c.
Program Statement submitted to the county and the provider
is in the process of completing revisions. _______________________
Expected Completion Date
d.
Program Statement & Letter of Recommendation submitted to CCL. _______________________
Date
e.
Program Statement & Letter of Recommendation submitted to CCL and the provider is in
the process of completing Program Statement revisions. _______________________
Expected Completion Date
Provide specific details about the program statement review or status of program statement revisions
being made. Also, provide details about actions taken that will effect capacity (i.e., number of
contracts that will or may be awarded and if an RFP has been submitted:
FC 30 (11/17)
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