Form Soc 2250 - Application For Qualified Agency Certification Page 2
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19.
HAS THIS AGENCY/BUSINESS PREVIOUSLY APPLIED FOR CERTIFICATION WITH CDSS?
YES
NO
IF YES, AGENCY/BUSINESS NAME________________________________________________________________ DATE APPLIED___________________________
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20. IS THIS AGENCY CURRENTLY IN CONTRACT WITH A COUNTY OR PUBLIC AUTHORITY TO PROVISION IHSS?
YES
NO
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COPY OF CONTRACT ATTACHED
IF YES, ENTER COUNTY/PA NAME________________________________________________________________ DATE CONTRACT EXPIRES_________________
21. AGENCY AGREES AND ATTESTS TO ALL OF THE FOLLOWING:
A.
GUARANTEES THE CONTINUITY AND RELIABILITY OF SERVICES TO RECIPIENTS.
•
THE AGENCY SHOULD HAVE SUFFICIENT FUNDING TO SUSTAIN 180 DAYS OF IHSS OPERATING EXPENSES.
•
THE AGENCY MUST MAINTAIN A PHYSICAL BUSINESS STRUCTURE TO OPERATE WHICH MUST BE IN A PROPERLY ZONED LOCATION FOR A
BUSINESS, CANNOT BE OPERATED FROM A PRIVATE RESIDENCE, AND MUST HAVE SUFFICIENT OFFICE SPACE, EQUIPMENT, AND SUPPORT TO
FULLFILL ITS REQUIREMENTS TO PROVIDE IHSS.THE AGENCY SHALL CONFIRM THAT IT HAS NOT BEEN THE SUBJECT OF BANKRUPTCY
PROCEEDINGS WITHIN THE LAST FIVE (5) YEARS FROM THE DATE ENTERED ON THIS APPLICATION.
B.
GUARANTEES THE SUPERVISION OF CONTRACT PROVIDERS.
•
THE AGENCY WILL HAVE SUFFICIENT PROVIDER STAFFING TO MEET ITS SERVICE OBLIGATIONS. EACH PROVIDER WILL BE PROPERLY TRAINED,
SUPERVISED, AND MONITORED THROUGHOUT THEIR EMPLOYMENT TENURE. SUPERVISORY STAFF SHOULD BE AVAILABLE ON-CALL 24 HOURS
PER DAY, 7 DAYS PER WEEK. THE AGENCY IS CAPABLE OF PROVIDING HIGH-QUALITY AND RELIABLE IN-HOME SUPPORTIVE SERVICES.
C.
GUARANTEES EACH CONTRACT PROVIDERS HAS BEEN SCREENED IN ACCORDANCE WITH WELFARE AND INSTITUTIONAL CODE SECTIONS 12305.81
AND 12305.87.
•
THE AGENCY SHALL PERFORM FINGERPRINTING AND BACKGROUND CHECKS WITH THE CALIFORNIA DEPARTMENT OF JUSTICE ON ALL
EMPLOYEES THAT WILL BE PROVIDING IHSS SERVICES. THE AGENCY SHALL NOT EMPLOY AS AN IHSS PROVIDER ANY PERSON THAT IS
INELIGIBLE TO BE A PROVIDER DUE TO A CONVICTION FOR CERTAIN CRIMES WITHIN THE STATUTORY FRAMEWORK OF WIC SECTIONS 12305.81
AND 12305.87.
E.
GUARANTEES THAT EACH PROVIDER IS CAPABLE OF AND IS PROVIDING THE SERVICE AUTHORIZED.
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THE AGENCY SHALL RECORD AND MAINTAIN PROPER DOCUMENTATION OF PROVIDER EMPLOYEE AND RECIPIENT INFORMATION AVAILABLE
FOR REVIEW BY CDSS UPON REQUEST.
F.
THE AGENCY GUARANTEES COMPLIANCE WITH ALL APPLICABLE RULES AND REGULATIONS REGARDING CIVIL RIGHTS.
G.
THE AGENCY IS CAPABLE OF PROVIDING HIGH QUALITY AND RELIABLE IN-HOME SUPPORTIVE SERVICES.
H.
THE AGENCY IS CAPABLE OF COMPLYING WITH ANY RULES OR REGULATIONS PROMULGATED UNDER THE WELFARE AND INSTITUTIONS CODE AND
ANY APPLICABLE FEDERAL RULES AND REGULATIONS.
I.
THE AGENCY HAS NOT DEMONSTRATED A PATTERN AND PRACTICE OF VIOLATIONS OF STATE AND FEDERAL LAWS AND REGULATIONS BASED ON
ANY AVAILABLE INFORMATION.
22.
AGENCY UNDERSTANDS THE RIGHT TO APPEAL REGARDING THE DISPOSITION OF THIS APPLICATION AND/OR CERTIFICATION PROCESS.
23.
UNDER THE PENALTY OF PERJURY, I/WE HEREBY CERTIFY THAT I AM/WE ARE A RESPONSIBLE PARTY AND AUTHORIZED REPRESENTATIVE OF THE AGENCY
AND HAVE THE LEGAL AUTHORITY TO EXECUTE THIS APPLICATION AND ATTESTATION FORM ON BEHALF OF THE AGENCY AND THAT THE INFORMATION
CONTAINED HEREIN IS TRUE AND CORRECT.
SIGNED_______________________________________ TITLE______________________________ COUNTY______________________ DATE_________________
SIGNED_______________________________________ TITLE ______________________________COUNTY______________________ DATE _________________
STATE OF ________________
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}ss.
COUNTY OF ______________
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On ____________ before me, ____________, a notary public, personally appeared _____________________________ ,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within
instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that
by his/her/their signature(s) on the instrument the person(s)) or the entity upon behalf of which the person(s)) acted, executed
the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and
correct.
WITNESS my hand and official seal.
Signature _____________________________
(This area for official notarial seal.)
SOC 2250 (3/14)
PAGE 2 OF 4
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