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. ADDITIONAL SPACE OR ATTACH SEPARATE SHEET
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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 .