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HomeMy WebLinkAboutMINUTES - 06151996 - 1.72 TO, BOARD OF SUPERVISORS s L Contra 2 . FROM: PERFECTO VILLARREAL, DIRECTOR f SOCIAL SERVICE DEPARTMENTS � !z Costa 'Yta 40 DATE: JUNE 1, 1993 County ,,�=-`ca�aT' SUBJECT: APPLICATION FOR RENEWAL OF COUNTY ADOPTION AGENCY LICENSE SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION I. RECOMMENDATION Approve and authorize the Chair to sign the annual application of the State Department of Social Services for renewal of license to conduct a County Adoption Services for the period July 9, 1993 through July 8, 1994. II. FINANCIAL IMPACT All positions and costs related to staffing and conducting the Social Service Department's Adoption Unit are included in the Department's budget projections for FY 1993/94. III. REASON FOR RECOMMENDATION The regulations of the State of California require public and private adoption agencies to apply annually for renewal of their adoption licenses. Contra Costa .County's license enables the Social Service Department's Adoption Unit to accept relinquishments and place children for adoption in accordance with the California Administrative Code, Title 22 , Division 2 , Chapter 3. CONTINUED ON ATTACHMENT: YES xSIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTIFE APPROVE OTHER SIGNATURE(S): ACTION OF BOARD ON June 15, 1993 APPROVED AS RECOMMENDED X OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE X UNANIMOUS(ABSENT /v ) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. CC: Social Service Department ATTESTED June 15, 1993 County Administrator PHIL BATCHELOR,CLERK OF THE BOARD OF State Depart. of Social Service SUPERVISORS AND COUNTY ADMINISTRATOR BY DEPUTY M382 (10/88) STATE OF CILIFORwIA—HEALTH AND S7ELFARE AGENCY APPLICATION FOR ADOPTION AGENCY LICEN-SE .RE?{EXAL ADDRESS REPLY TODEi` ENT OF SOCIA Si:I.VICI:FAC . CON'1-N1U`[TY CARIE LICE\SI\G DATE LIC . EXPIRES : 0i0 Moorpark Suite 215 EVAL . CODE:. San Jose, CA 95117 ADOPTION AGENCY NAME : AGENCY ADDRESS : AGENCY MAILING ADDRE55 : }� 1 (IF DIF r ERENT) "t� Pc5 'R{vt �+��; +� Z AGENCY TELEPHONE NUMBER : Eti:CUTTVE DIRECTO R :. Rfec � 6,,vr �� CU ' , _NT LIM.lTA : 1O,1S 0m L i CZ'Y S E : Y Z 4�` �-4+V` �5111�11CJw �'ti^• Please complete the following items : ( .. Geographic c rem "C be served : 2. Check 1 here �[ = : the pr enz- nied 1 .^.= or:Zazloc, or h S - arm is incorrect- or any chan.ae in agency program, plan_ of operation or organization has been made , explain gully below or on an add.itionai she_= any correcti. c.rs or changes . 3 . Complete the attached 7o-, = LTC 278E describing the aaenc f -program— This application is not camalete unless .the attache-- pages-'are 'completed and subm=it:ed with this for=- STATE OF CALIFORNIA HEALTH AND WELFARE AGENCY DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION • f UATL SUPPORTIVE INFORMATION FOR APPLICATION OR RNEWAL OF LICENSE TIME OF APPLICATION NEW RENEWAL PUBLIC AGENCY COUNTY WELFARE DEPARTMENT � ❑� DIRECTOR SIGNATURE PRIVATE AGENCY NAME PLEASE ATTACH AN ORGANIZATION CHART OF YOUR AGENCY Reference: California Administrative Code; Title 22, Division 6, Chapter 4; California Administrative Code, Title 22, Division 2, Chapter 3; Welfare and Institutions Code; Health and Safety Code I- LICENSING APPLICATION A. LICENSING YES NO 1. Agency is licensed to operate in the following geographical area: IU T 2. Do you provide services in other geographical areas? It yes, please explain: ❑ B. OPERATIONAL PLAN FOR PROVIDING ADOPTION SERVICE INCLUDES: 1. Statement of program goals and services 2. Written policies and procedures for implementing the following: a. Services and assistance to mothers not eligible for public funds. b. Coordination and utilization of public social services. ❑ C. Aid for Adoption of Children Program. d. Hearing and Appeal Procedures. ❑ e. Adoption Resource Referral Center. ❑ I. Maternity Care Plan ❑ If answer is "NO" to any of the above, please explain: LIC 278 0 14181) PAGE i OF 4 -tl.' ORGA�dIZAT10N AND ADMINISTRATION - - .--.�—Yy A. ADMINISTRATION YES NO 1. California Administrative Code, Title-22, Division 6, Chapter 4; the Welfare and Institutions Code; and other regulatory and guide materials available for staff use. EJ If answer is "NO", please explain: 2. Staffing a. Supervisors 1. Number of positions authorized 2. Number possessing MSW ` 3. Number with one year graduate social work training' }---�� (a) Classification 4. Number with college graduation only (b) Classification 5. Number of vacant positions b. Adoption Caseworkers 1. Numbers of positions authorized 1 2. Number possessing MSW 3. Number with one year graduate social work training (h) Classification 4, Number with college graduation only (a) Classification 5. Number with less than college graduation (a) Classification 6. Number of vacant positions 3. Adoption services are provided as follows: a. Services to natural parents considering relinquishments. Lad b. Acceptance of applications. c. Services for children in pre—adoptive care for a reasonable period of time. d. Recruitment, selection, and study of adoptive homes. e. Selection, placement, and supervision of children in adoptive homes. . PAGE 2 OF 4 )� I. Completion of necessary documents and records and reporting to the court in YES NO finalizing adoptions. ❑ g. Services to adoptive families when, after adoption is final, specific information ❑ is needed on a child or limited services are necessary. h. Services to natural parents after relinquishment related to the relinquishment. ® ❑ i. Referral service as appropriate to other county or community agencies when ❑ continuing services needed. - If the answer Is "NO" to any of the above, please explain: 4. Supportive services are available as follows: a. Income maintenance and/or.General Relief. `�' ❑ b. Foster home certification. ❑ c. Supervision of children in long—time foster care, children in free foster home ❑ care, or children who have legal guardians. d. Medi—Cal eligibility determination and service. ❑ e. Post—adoptive services to natural parents and adoptive families other than ❑ services for which adoption is responsible. I. Medical, psychiatric, and psychological consultation. a ❑ If the answer is "NO" to any of the above, please explain: IN 5. Fees: Assessment and collection. a. Number of full fees (last fiscal year). b. Number of reduced fees assessed (last fiscal year). c. Number of fees waived (last fiscal year). d. Agency fee policies incorporate: 1. Reduction, deferment, or waiver assessed on the basis of economic hardships ❑ to the family detrimental to the welfare of the child. 2. Narrative record-with marginal heading for identification to support the ❑ fee agreed upon. 3. Written placement agreement to include fee agreed upon. .. n ❑ �`�' PAGE 3 OF 4 4. Agency's responsibility to complete the adoption and file a favorable report not YES NO delayed by the family's failure to pay the fee or complete the payment plan. .-5,. Administrative approval for assessment and collection of fees. ❑ It the answer is "NO" to any of the above, please explain: IIV. AGENCY OFFICES A. OFFICE FACILITIES —ADOPTION AGENCY 1. Provide privacy and confidentiality for interviewing. El 2. Conveniently located for the public. B. CASE RECORDS — RELINQUISHMENT PROGRAM 1. A case record is maintained for each family unit or individual served in the adoption placement program. a. Written narrative records contain information to substantiate decisipns and ❑ plans of action. b. Individual records contain the information as required in Section 30569 (b), ❑ 2. Confidentiality is maintained for all information in adoption case records (Section 30569 (c)). 3. Access to case records to protect confidentiality is maintained by: C. CASE RECORDS — INDEPENDENT PROGRAM t�, 1. Content of information in case records is in compliance with Section 30571 (a)--/ 2. Completed case records a.re.returned to.SDSS for permanent filing. (Section 30571 (b)) 3. SDSS notified immediately in cases of (Section 30567): a. Contested actions. b Petition filed in an appellate court. c. Appeal filed in any guardianship or custody action involving a child who is subject to adoption. d. Case documents as required in Section 30573 are filed with SOSS. El If answer is "NO" to any of the above, please explain: STATE OF CALIFORNIA-HEALTH AND WELFARE AGENCY DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DESIGNATION OF ADMINISTRATIVE RESPONSIBILITY Licensed facilities are required to have an authorized person continuously present at the facility during operational hours to represent the facility and to accept licensing reports. Licensees who cannot and applicants who anticipate that they cannot be continuously present at the facility shall use this form to delegate the above authority to the administrator or other appropriate staff. Applicants/licensees who are corporations shall attach board resolutions authorizing this delegation. Facility Name •� k Date Facility Number Facility Address \k'A \W*Z � �{ Phone f Zia City cz_ County `04W,C-4',IN I designate V a N N E �u� 0 C,� �5 S 1 S 1 Aya ��kSS' kas administrator, manager,or agent of the above-named facility. He/She is authorized to receive any documents including reports of inspections and consultations, accusations and civil and administrative processes on my behalf at the above-named facility. I (We)shall notify the Licensing Agency in writing, within 10 days of any change in the above authorization. Residential Care Facilities for the Elderly shall comply with Section 87563 regarding this requirement. Day care centers shall comply with Section 101312 regarding this requirement,other licensed facilities shall comply with Section 80064. Signature of licant(s)/licensee(s) Title y Address citj Y County Zip LIC 308(2191)(PUBLIC) . STATE OF CALIFORNIA-HEALTH AND WELFARE AGENCY DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING ADMINISTRATIVE ORGANIZATION (This side is for corporations only. See reverse for public agencies,partnerships, DATE and other associations.) FACILITY NAM INSTRUCTIONS: This form must be updated and submitted to the Licensing Agency each time. FACILrrvADDRES`s there is a change in partners, officers or changes in the corporation as 0 00. provided in regulation Section 80034(a)(2),or 87235(a)(5),or.101185(a)(2). FACILrry NUMBER I. CORPORATION 1. Name(as filed with Secretary of State) 2. Chief Executive Officer 3. Incorporation Date 4. Place of Incorporation I Corporation Number 5. Please attach (1) A copy of Articles of Incorporation and any amendments ..(2) A copy of By-Laws and any.amendments (3) A copy of Resolution authorizing the filing of this application. 6. Principal office of business: Address Qiu Zip.Code County Telephone No. Contact Person: Title: Telephone No• 7. Out of state or foreign applicants complete the following: a. Name of California Reoresentative Address zjpCode Telephone No- b. Please attach a copy of authorization of a foreign corporation to do business in California. 8. Names and addresses of all persons who own ten percent(10%)or more of stock in corporation. See Section V for additional space. 9. Governing Board of Directors: a. Number of Board Members b. Term of Office c. Frequency of Meetings d. Method of Selection 10. Board Officers: Office Name Principal Business Address 3 City&Zip Code Telephone No. Term Expires President Vice-President Secretary Treasurer LIC 309(12J89)(PUBLIC) II. PUBLIC AGENCY 1. Check type of public agency: .. ❑ Federal ❑ State County ❑ City ❑ Other,specify below 2.• Agency providing services:. . C, Name: ` Address: \t�`, _ a C� C STATE Mailing Address: C C\R�' 1 �5� -6f, � p CRY/STATEOP CODE Contact Personl� t/� 6 5\'M Title: Phone No.: 3. District or Area to be served: (attach map i/necessa�, Specify geographic area: 4. Attach copy of Resolution or legal document authorizing this application. III. PARTNERSHIPS Attach a copy of partnership agreement 1st Partner ❑ General Name ❑ Limited Principal Business Address CITY/STATE 2nd Partner ❑ General Name ❑ Limited Principal Business Address CITY/STATE 3rd Partner ❑ General Name ❑ Limited Principal Business Address CITYISTATE 4th Partner ❑ General Name ❑ Limited Principal Business Address CITYISTATE Contact Person: Title: Telephone No.: See Section V for additional space IV. OTHER ASSOCIATIONS Other associations must also provide a similar list of persons legally responsible for the organization,contact person,appropriate legal documents which set forth legal responsibility of the organization and accountability for operating the facility. V. 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"::.':.'::':. ..... . :.................. :::.::::'::::.::::.:::.::::.::::::::.::.:... :... ' ....:'.:..:.:�:.:. ..:...::.:.:.:::.::: :::.. .. :..:;::::.;.: ..::.:'..::....::::::. .. ..:..;::.:::.:: ..:..;.:.:;::::::.. .:........: ..........: :.::...:::: 1 , Z` CEE;IFIxIt3H I accept responsibility to comply with the .Health and Safety Code and administrative regulations concerning adoption agency licensing. , Signalre title Uatei Chair, Board of 6115193 i g n a t u r e t4La l e Superv.isorS Date ; Signature itle Date ; Public agency renewal applications must be signed by the Chairman of the Board of Sepervlsors and accompa .n.ied by a Copy cf the Board Resolution 'a-uthori=l rig this application and SlC-,12 ,u e by t h e Ch a i-rr,.a n . Pr i vai. e agency rene'.+als must be signed b the C h a:rutan o: zhe Board - of Dlrector5 and accompanied by a Copy of the author_zat?on by the board to its representative to m2ke application . Please note that an appllCation for rene,,;G of license shall be filed with the Department of Social Services not less than 0 days prior to the e x p i r a t i a r date o? --'%he C':r r nn- iicenze . C a i 1 u r e to filake app 11 cation w i t h i tN In p es c be^. time sha _i resu t : n expiration of the, license .