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Home My WebLink AboutRESOLUTIONS - 05162006 - C.40 TO: BOARD OF SUPERVISORS �� Contra FROM: FINANCE COMMITTEE g r, be s Costa DATE: MAY 4, 2006 e = -ST- COUK County SUBJECT: STATUS OF CORRECTIVE ACTIONS ON FINDINGS EMANATING FROM THE O COUNTYWIDE SINGLE AUDIT FOR THE PERIOD ENDING JUNE 30, 2005 C , SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATIONS: 1. ACCEPT report prepared by the County Administrator on corrective actions taken in response to findings emanating from the Countywide Single Audit for the period ending June 30, 20.05. 2. ACKNOWLEDGE the auditor's verification that reportable conditions cited in the auditor's prior-year reports did not recur in fiscal year 2004/05. 3. ACKNOWLEDGE that the audit report reflected positively on the County's overall internal financial controls, financial reporting, and compliance with federal rules and regulations. BACKGROUND: On May 4, 2006, our Committee received the attached report prepared by the County Administrator on corrective actions taken in response to findings emanating from the Countywide Single Audit for the period ending June 30, 2005. We are satisfied with the progress and direction of proposed corrective actions and recommend that the Board accept the County Administrator's report. CONTINUED ON ATTACHMENT: YES SIGNATURE'Y� : RECOMMENDATIO OU DMINISTRATOR RECOMME ION OF BOARD COMMITTE APPROVE 0TH R SIGNA RE(S): AR PIEPHO JOHN GIOIA ACTION OF -_ N APPROVE AS RECOMMENDED O R VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF AN ACTION TAKEN UNANIMOUS(ABSENT AND ENTERED ON THE MINUTES OF THE BOARD OF SUPERVISORS ON THE DATE AYES: NOES: SHOWN. ABSENT: ABSTAIN: ATTESTED: MAY 16,2006 CONTACT: LISA DRISCOLL(925)335-1023 JOHN SWEETEN,CLERK OF THE BOARD OF SUPERVISORS AND COUNTY ADMINISTRATOR CC: FINANCE COMMITTEE STAFF COUNTY ADMINISTRATOR(ENEA) EMPLOYMENT AND HUMAN SERVICES DIRECTOR' COMMUNITY SERVICES DIRECTOR HEALTH SERVICES DIRECTOR BY PUTY County of Contra Costa Office of the County Administrator MEMORANDUM DATE: April 26, 2006 TO: FINANCE COMMITTEE: Supervisor Mary N. Piepho, Chair Supervisor John Gioia FROM: JOHN CULLEN, Coun Administrator By JULIE ENEA� or Deputy County Administrator SUBJECT: COUNTYWIDE S GLE AUDIT FOR THE FISCAL YEAR ING JUNE 30,2005 On November 8, 1999,the Board established a policy and procedure for addressing the annual findings and recommendations of the County's external auditors. The procedure directs that the Board refer the annual Single Audit findings to the Finance Committee, and that the County Administrator make a report to the Finance Committee on the current- and prior-year audit findings and recommendations that identifies what corrective action has been taken or is planned to be taken on each recommendation. Inasmuch as the current year Single Audit report encompasses all unresolved or pending audit issues from prior-year audits,this report responds directly to the current-year Single Audit report(FY ending June 30, 2005), which was transmitted to the Board of Supervisors on April 11, 2006. Financial Reporting. Government Auditing standards require the external auditor to obtain reasonable assurance that the general-purpose financial statements are free of material misstatement. The external auditor found no reportable instances of non-compliance or internal control inadequacies with regard to financial reporting. Program Requirements. Government Auditing Standards and OMB Circular A-133 (which is applicable to federal programs)require the external auditor to report on both compliance with and internal controls over the major federal programs carried out by the County. On the whole, the 2005 Single Audit report reflected very positively on the County, citing three reportable conditions involving compliance, and internal control over compliance, with OMB A-133.• The auditor found no material weaknesses that are required to be reported. The reportable conditions relate to required income eligibility documentation that was found to be missing from a sampling of case files for programs administered by the Employment and Human Services, Community Services, and Health Services departments, as described in the following report: Finance Committee April 26,2006 Page 2 Countywide Single Audit Follow-up Finding 05-1: Workers Investment Act Grant—Youth Recommendation: The auditor recommended that the County strengthen its controls by providing periodic review of applicant files to ensure that all necessary documentation to support the applicants' eligibility has been obtained. Background: During the audit,the auditor noted that two of the ten applicants tested did not have income verification documented in the applicants' files. Documentation of income verification needs to be maintained in order to verify the eligibility of the applicant to participate in the program. Corrective Action: To correct this deficiency, the Workforce Development Board will assign its case management supervisors to quarterly review Workforce Investment Act Youth files. A limited number of files will be selected randomly, excluding files reviewed within the last 12 months. A quarterly file review checklist, Attachment A, has been developed and will serve to guide,facilitate, and document the review of each file selected. One copy of each checklist will be held in a central file at the Workforce Development Board office and a second copy placed in the participant's file. Case managers will immediately correct any case files found to be missing required case documentation. Corrections to incomplete or inaccurate files will be noted on the quarterly review for tracking purposes. ♦ Finding 05-2: Head Start Grant Recommendation: The auditor recommended that the County strengthen its controls by providing periodic review of applicant files to ensure that all necessary documentation to support the applicants' eligibility has been obtained. Background: During the audit,the auditor noted that two of the ten applicants tested did not have income verification documented in the applicants' files. The Head Start Grant agreement requires that the income of applicants be verified to determine eligibility. Documentation of income verification needs to be maintained in order to verify the eligibility of the applicant to participate in the program. Corrective Action: In response to the auditor's finding, Community Services Department has implemented these internal control procedures to ensure compliance with Head Start eligibility requirements: v The Department has restructured the approach to enrolling and certifying families. In the past,the Family Advocate and Site Supervisor were responsible for gathering the necessary documentation and certifying the eligibility of the family. Under the new structure, a Comprehensive Services Team(CST) Assistant Manager, specializing in eligibility, certifies the eligibility of every parent and gathers the documentation for the file. All files must be approved by the CST Manager before the child enrolls. The Finance Committee April 26,2006 Page 3 Countywide Single Audit Follow-up error rate has declined considerably since this restructure. Please see attached protocol outlining the steps for enrolling a child. Attachment 1 • The family income must be verified by staff and copies collected for verification before determining that a child is eligible to participate in the program. Staff verification must include examination and collection of any of the following: Individual Tax Form 1040/1040A/I040EZ, W-2 forms,pay stubs, employment verification from employers, self-declaration of stated income or documentation showing current status of public assistance. A new income verification form has been developed that requires the employee certifying eligibility to sign that they have reviewed the documentation and to the best of their knowledge, the information is accurate. Attachment 2 • Additionally, staff is now required to use a checklist form that lists the items that need to be reviewed prior to enrollment. Attachment 3 • All children's files now have a cover sheet in the file with a checklist indicating the required documents for each section. Please see attached eligibility checklist. Attachment 4 • Site Supervisors and Comprehensive Services Team members are required to conduct monthly reviews of children's files to make sure they contain all the necessary income documentation required by Head Start regulations. Please see monitoring schedule. Attachment 5. • Assistant Directors review a five percent sample of the enrollment files in their Clusters monthly and the results are reported in the monthly report to the Deputy Director and Fiscal Officer. • As the new Comprehensive Services System was developed and implemented in 2005,training was conducted for the Comprehensive Services Team and the Site Supervisors. Additional staff training regarding documentation procedures and Head Start eligibility requirements has been scheduled. Training was conducted throughout the month of April regarding the required income documentation necessary for enrollment. Please see attached training schedule. Attachment 6. ♦ Finding 05-3: Substance Abuse and Mental Health Services Block Grant(SAMHSA), Recommendation: The auditor recommended that the County strengthen its controls by requiring that detailed supporting documentation for amounts claimed be maintained. Background: The SAMHSA Grant agreement requires that the County maintain applicant files which contain verification of the applicants' identity and inability to pay for services to determine eligibility. Maintaining detailed records to support the amounts claimed for Finance Committee April 26,2006 Page 4 Countywide Single Audit Follow-up reimbursement serves as a means to test and verify the eligibility of the applicants that participated in the program. The Health Services Department does maintain evidence of inability to pay for services in the individual client files. However, during the audit, the auditor noted that the Department did not retain the detailed client services reports—that is, a complete list of all clients who received services—used to prepare its claim for reimbursement under the grant. Corrective Action: The Health Services Department has programmed a new report to re- create the list of clients that served as the basis for the 2005 reimbursement claim. This report can be generated annually to document the clients' identities and income eligibility for all service cost reimbursements claimed by the County under the grant. The County committed to have the new report available no later than April 15, 2006 and the new report has been developed and is now available. ♦ Finding 04-1: Community Services Block Grant Recommendation. The auditor recommended that the County strengthen its controls by providing periodic review of functional timesheets to ensure that they are prepared correctly and in a timely manner. Back rid. The auditor found that the salaries of the advocates for 37 families charged to the Community Services Block Grant were not supported by functional timesheets. Instead of charging staff salaries to the Grant on the basis of functional time, staff time was estimated and a journal entry was prepared to charge the Grant for a portion of their salaries. Corrective Action. In response to the auditor's finding and recommendation,the Community Services Department developed and implemented the following internal control procedures to ensure adherence to eligibility requirements required by OMB Circular A-133: Timesheets are completed by staff and timely filed: ■ Timesheet schedules for the whole year are sent to all CSD employees in early January. ■ Timesheet schedules are also calendared in Outlook(department-wide electronic scheduler) for reference by all CSD employees of due dates for submission of timesheets. ■ Payroll clerks review all timesheets submitted and match them with their employee lists. If there are missing timesheets, the CSD fiscal unit sends a notice to the subject employee(s)to prompt for submission of timesheets. Periodic verification that timesheets are being completed and timely filed: ■ Supervisors are required before approving timesheets to verify that employees have charged in their timesheets the correct organizational unit and time code for work performed. ■ Since January 1, 2005, in addition to supervisory review, the Assistant Family Services Managers review the Intermediate Clerks' timesheets each pay period to Finance Committee April 26,2006 Page 5 Countywide Single Audit Follow-up ensure that work performed under the Community Services Block Grant Program is properly coded and reported. In the current year audit, the auditor found that the corrective actions described above had been implemented and the conditions noted in the prior-year audit did not recur. Attachments cc: Joe Valentine, Community Services Director Eric Pormento, CSD Fiscal Officer Danna Fabella,Acting Employment and Human Services Director George Washnal,Health Services Controller Tim Ernst, Chief of Audit Services,Auditor-Controller's Office Dorothy Sansoe,Senior Deputy County Administrator-Health& Welfare WIA YOLtThtAND YOWLWI ADI.0-TS SERVICES Q- l RT6121_y 1=1LE R6V15W CFtECKUST (Place A 61eclp-Lf�wserted �w the fUe folder) ------------------------------------ .. Label A I. WIA Application ❑ 2. WIA Enrollment/Registration ❑ 3. WIA Goals ❑ 4. Contact Information ❑ 5. WIA/WtW Advertisement of Rights ❑ 6. EastBay Works Application for Services ❑ 7. CA I.D. or Drivers License ❑ 8. Social Security Card 9. Certificate of Live Birth ❑ 10. Selective Services ❑ 11. Immigration or Naturalization documents 12:Passport 13.Income Months pay stub ❑ Income Tax Form F-1Unemployment Benefits ❑ 14.Miscellaneous HUD Form ❑ Medical ❑ WIC documents ❑ Infant Birth Certificate&Social Security Card ❑ Letter of Residency ❑ PG&E ❑ Phone Bill ❑ Food Stamps ❑ GA ❑ Quarterly File Review Date: Completed by: DRAFT K;p 6A{y� Contra Costa County Community Services Department Staff Protocols for: ERSEA and Comprehensive Services . January 2006 Attachment 1 ERSEA and Comprehensive Services Table of Contents ERSEA.................................................................................................4 Recruitment................... Maintaining Eligible/Accepted Families............................................ 4 Enrollment/Placement....................................................................... 6 Recertification/Re-enrollment........................................................... 7 Re-enrollment Process ..................................................................... 8 Terminating Children from Program ................................................. 8 Attendance Reporting....................................................................... 8 Monitoring and Tracking................................................................... 9 HEALTHSERVICES .........................................................................11 Application....................................................................................... 11 Immunizations................... HealthHistory ................................................................................. 12 PhysicalExam ................................................................................ 13 Vision and Hearing Screening........................................................ 14 DentalExam ........................................:.......................................... 15 MedicalHome................................................................................. 16 Referrals.......................................................................................... 16 Monitoring and Tracking................................................................. 17 NUTRITION........................................................................................18 NutritionReferral............................................................................. 18 "At Risk of Overweight & Overweight............................................ 18 PickyEaters.................................................................................... 19 Food Allergy and Special Diets ...................................................... 19 Heightsand Weights...... ............................................................... 19 CACFP (Child Adult Care Food Program)...................................... 20 4/4/2006 2 Addition/Deletion........ .................................................................. 20 CA CFP Monitoring............................................................................ 20 Monitoring and Tracking................................................................. 21 MENTAL HEALTH REFERRALS .....................................................22 ReferralForm.................................................................................. 22 Monitoring and Tracking................................................................. 23 DISABILITY REFERRALS................................................................25 ReferralForm.................................................................................. 25 Monitoring and Tracking.......................... ............ 26 ........................... PARENT INVOLVEMENT.................................................................28 Parent Interest/Volunteer Surveys.................................................. 28 Family Partnership Assessments/goal........................................... 28 Additional Forms............................................................................. 29 PolicyCouncil................................................................................. 29 AsNeeded.........................................................................................29 ParentMeetings........ .................................................................... 30 FamilyServices............................................................................... 31 Monitoring and Tracking................................................................. 31 AppendixA .......................................................................................... AppendixB ........................................................................................VI 4/4/2006 3 ERSEA Recruitment Ongoing • All staff, parents, Policy Council members, and partners o Give out flyers, etc., in accordance with annual Recruitment Plan. • All CSD staff Ongoing o Phone calls: refer to Comprehensive Services Clerk for that center or program. o Walk-ins: All staff assist client in filling out CSD-690 Waiting List Pre-Registration Form. • If client has brought in any documentation, such as pay stubs and/or birth certificate, make copies and staple to the waitlist form. • Fill in all sections of the form. • Put documents in a sealed envelope, with name and location of Comprehensive Services Clerk who supports the PRIMARY desired location of child care, as requested by the client. Mark CONFIDENTIAL on envelope. • Place in Comprehensive Services box at site. o Mail received: • Route to appropriate person if mail came in self- addressed envelope. • If not, send to Comprehensive Services Clerk who supports that center or program. • Staff for the pre-registration phone numbers Ongoing o Take basic pre-registration information over the phone or in person and enter into COPA. Maintaining Eligible/Accepted Families Ongoing • Comprehensive Services Clerks Ongoing o Take basic pre-registration information over the phone or in person and enter into COPA. o Conducting interviews: • Determine income eligibility based on family size. 4/4/2006 4 • If client has come in with documentation, e.g., pay stubs, birth certificate, immunization papers, make copies of documents. o Create and sign and date income calculation sheet. o Establish a temporary file for the child (CSD Eligibility/Enrollment checklist). o Make notation on child data sheet in COPA as to the location of the temporary file. o Temporary file should remain with the Comprehensive Services Clerk who supports the PRIMARY desired location requested by the family, until file is ready to be reviewed by the Comprehensive Services Assistant Managers. • Note: Eligible/Accepted temporary files are retained by the Comprehensive Services Assistant Manager. o Keep the file in a locked drawer or cabinet. o Collect the following information in the temporary file: • Copy of the child's birth certificate or other age verification. • Parents' income verification (e.g., pay stubs) or self- certification form, if applicable (signed & dated). • Income calculation worksheet (signed & dated). • Copies of the child's immunization records, unless child is less than 18 months of age, (not necessary to determine eligibility). • Health history from COPA (signed and dated). • Child Care Data Collection Privacy Notice and Consent Form. o Once file has been determined eligible by Comprehensive Services Assistant Manager: • Review and update information on file. • Review and update Child and Family Data sheets. • Review Health History. • Update Emergency Information (CSD 214) • Flag if case conference is needed prior to enrollment. • Comprehensive Services Assistant Manager Ongoing o Review temp file from Comprehensive Services Clerk. 4/4/2006 5 o Verify family eligibility. o Move child from Eligibility Waiting List to Eligible/Accepted Wait List in COPA once eligibility has been established. o Retain possession of temporary file until requested by a Site Supervisor or other Comprehensive Services team member. o Update Child Data sheet in COPA to reflect location of temporary file. • Assign task of transferring documents from temporary file to permanent child's file when Site Supervisor requests the file for potential enrollment/placement. o Check files for flags. • Ensure flagged items are properly noted in COPA o Keep file in a locked drawer or cabinet. o Maintain Eligible/Accepted list in COPA o Purge Eligible/Accepted list on COPA record of over-age children (except Verde and Lake). o Send purged list into COPA archive. Enrollment/Placement Ongoing • Site Supervisor o Review Eligible/Accepted List in COPA. o Select the child with the highest priority. o Secure file from the Comprehensive Services Assistant Manager via e-mail or phone call request using child's COPA ID#. o Review all sections of child's file for special needs or concerns and accuracy. o Check for any flagged items that may need follow up or a parent/guardian signature. o Coordinate/schedule Case Management Meeting with parent, Comprehensive Services Assistant Manager, and other staff as needed. o Contact parent for enrollment (placement) appointment. o Advise family to bring any documents that are needed to update file. o When meeting with family: • Complete, date and sign new income information as needed and enter updated information on COPA. 4/4/2006 6 • Print the 9600 form from COPA to be signed and dated by site supervisor and parent/guardian • Issue Notice of Action. • Update Emergency Information (CSD-214). (Note: the Licensing Emergency ID/Information form is no longer to be used.). • Complete CCFP application. • Complete Admission Agreement and hours of service contract. • Complete Parent Handbook with parent. • Verify that the child's immunizations are up-to-date (Do not admit until record is up to date). • Review health history and ensure appropriate referrals have been made. • Move child from Eligible/Accepted List and place into appropriate classroom and Program Model. • Double check COPA record to ensure match between paper file and COPA file. • Conduct final review of file for accuracy. Recertification/Re-enrollment Ongoing • Site Supervisor o Track families needing to be recertified using Recertification Tracking Calendar. o Notify families 30 days prior to enrollment expiration to bring updated eligibility documentation. o Collect recertification or re-enrollment documentation. o Complete new 9600 on COPA at face-to-face interview with parent. o Complete new income calculation sheet (signed and dated). o Proceed with certification procedures as listed above if family is still income eligible. o Issue Notice of Action, certifying continuation, changes or termination of services. (Note: adverse action requires a 14-day written notification, 19-days if mailed). o Drop file on COPA on the last day of service and prepare paper file for storage. o Update COPA record as needed. 4/4/2006 7 o Maintain files of terminated children in locked location at site for one year until after program audit in October or November. o Send dropped and files of terminated clients to central location after completion of program audit. Re-enrollment Process June & July • Site Supervisor o In June, identify children for roll-over. o In July, place roll-over children into appropriate classrooms and Program Model, from Eligible/Accepted list in COPA. o For previously enrolled GPRE child requesting re-enrollment, follow guidelines for completely new 9600 application with all new documentation: If a child's COPA record was archived within the program year, request Comprehensive Services Manager to reactivate child's COPA record and place child back on to Eligibility Wait.List • Follow standard guidelines for selecting children. Terminating Children from Program Ongoing • Site Supervisor o Issue Notice of Action 14 days prior to termination date. o Explain to parents the appeal rights. o If parent does not appeal termination: • Enter information regarding reason for ending services in COPA Child Data Sheet. Date and initial comments. • Change enrollment status in COPA. • Discontinue services on Family Data Sheet. • Determine if child may return within the program year. If so, place child back on Eligible/Accepted List. If not, archive the COPA record. o If parent appeals termination, send appeal notice to Assistant Director and continue to serve child until informed to move forward with termination. Attendance Reporting Monthly • Site Supervisor o Ensure accuracy of daily sign-in sheets. 4/4/2006 8 o Provide 801A's to AD by 5th of each month. o Provide 9400 Report to AD by 7th of each month. • Assistant Directors o Review and sign 9400 reports and submit to Attendance Clerk by the 10th of each month. o Send 801A to data entry clerk. o Conduct the hearing for appeals. Monitoring and Trackinq Ongoing • Site Supervisor, Home-based and Partner Managers . o Closely monitor enrollment, to ensure 100%. o Closely monitor sign-in sheets to ensure daily attendance. o Contact parents if attendance doesn't meet policy. o Refer clients with excessive absences to Comprehensive Services Manager for Family Services if needed. • Comprehensive Services Manager o Regularly monitor child's files for ERSEA compliance. • ERSEA Analyst o Closely monitor enrollment, and communicate results, to ensure 100% enrollment. o Monitor all aspects of ERSEA, to-ensure systems are being used correctly, and work with Assistant Directors and Comprehensive Services Managers to make any changes, as needed, to the established protocols. o Analyze gaps and anomalies. o Inform managers and Assistant Directors of findings and suggest corrective actions, as appropriate. o Review 9500 and 8501 to ensure contract earnings. o Review 801As for accuracy. o Maintain slots map. o Randomly monitor children's files for ERSEA compliance. o Report findings to Assistant Directors. 4/4/2006 9 • Assistant Directors o Review enrollment reports from ERSEA analyst and follow-up with Site Supervisors and/or Comprehensive Services Managers, as appropriate. o Review monitoring reports submitted,, work with other managers to make changes to the policies and procedures, if necessary, and help find solutions to any problems in maintaining ERSEA compliance. o Review 5% of cluster files each month. 4/6/2006 10 Contra Costa County Community Services Department Family Income Worksheet Family Name: Date: r� If Paid Weekly once per week Week 1 lWeek 2 Week 3 Week 4 Monthly Annual Primary Care Giver I 1 $0.00 $0.00 Week 1 lWeek 2 Week 3 Week 4 Annual Secondary Care Giver $0.00 $0.00 Total Family Income $0.00 $0.00 If Paid BI-Weekly (every other week 1 st.2 wks. 12nd.2 wks. Monthly Annual Primary Care Giver $0.00 $0.00 1 st.2 wks. 2nd.2 wks. Monthl Annual Secondary Care Giver $0.00 $0.00 Total Family Income $0.00 $0.00 If Paid Semi-Monthly (two times per month) First Second Monthly Annual Primary Care Giver 1 $0.001 $0.00 Secondary Care Giver $0.00 $0.00 Total Family Income $0.00 $0.00 If Paid Monthly (need two months check stubbs) First Second Monthly Annual Primary Care Giver 1 $0.001 $0.00 Secondary Care Giver 1 $0.001 $0.00 Total Family Income 1 $0.001 $0.00 Primary Caregiver Monthly Annual Money Wages or Salary 0.00 0.00 Net Income from Self Employment Social Security Public Assistance or welfare payments Pesnions and annuities or welfare payments Un-employment compensation/disability insurance Workers Compensation insurance Alimony Child support Veteran's Pensions Other Gross Monthly Income $0.00 Gross Annual Income $0.00 FAMILY SIZE I have reviewed this child's family income and indicated the type of income documentation examined above.I certify that income verification is complete and this child is eligible to participate in the programs: EHS HS/GWAP EHS/GCTR FCTR HS GPRE HS/GCTR GWAP HS/GPRE GCTR Staff: print name Attachment 2 Prepared by W.Davisson signature Updated by C.Reich 3-21-06 ELIGIBILITY/ENROLLMENT CHECKLIST ELIGIBILITY: Child's Name: Parent signature on Child Care Data Collection Sheet Child's COPA ID: Family size: Income Verification-pay stubs (for one month) Full day need assessment: Income Verification-Self Certification (if applicable) --employed/in training TANF if applicable) _seeking employment SSI(if applicable) —incapacitated Parent Training documents school schedule —per 'only _Home Base only Other: describe Site preferences: Income Calculation Worksheet w/staff signature 19t: 2nd, Child verification of age: (describe) 3': (CST Clerk/AM of 1't choice site maintains Child Immunization Record temp file until placement) Other documents if a Eligible for:applicable: EHS(Home Base) Children's Protective Services EHS/GCTR Foster Child Documentation HS(Home Base) HS art-da Child Special Needs documentation: 'Y' if applicable GPRE Type of Special Need: FCC GCTR • IEP/IFSP FTCR • Health/Medical illness, allergies HS/CPRE • Asthma HS/GCTR • Other: leasespecify) HS/GWAP Eligibility checked by: ENROLLMENT: Date: COPA Health History completed& signed Parent Orientation completed& receipt signed Forms given to parent to return: Volunteer Health Statement signed Employer verification Give parent Family Partnership Assessment& _Training Verification Goal to complete _Letter of Incapacitation Give parent Emergency Information form to _Physical complete _Dental Food Allergy form REVIEW OF DOCUMENTS: _Other: Review FPA& Goal All forms are signed by parent where applicable) Parent has stain ed envelo a to return forms Date above form(s) given: Comments: By Staff: Date: CSD-604-Eligibility Certification Checklist (Revised 01/06) Attachment 3 Contra Costa County Community Services Department COMMUNITY'SE RIV I C"EISI Enrollment Information DEPARTMENT Child's Name: Center: (EHS only) r 3rdyear. X Put In order 1.106ht,date-.,.,- �4ith"'Onb§tit J, Comments -.0 is n1ob.as initials. staff initials staff Notice of Action (if applicable) (CSD-7617) Enrollment Application Child Care Data Collection Privacy Notice and Consent Form Age Verification See Children's Records Review CCFP Application Form Filed at Child Nutrition Copy filed in site binder Income Verification Income Calculation Sheet with staff signature Fee Card (if applicable—see file) Waiver Form (if applicable) CSD-606 Eligibility CPS Every 3 Mos. (if applicable) Training Verification/Progress Documentation (if applicable) (CSD-612 + CD-9605) Statement of Incapacity (if applicable) (CD-9606) Employment Verification (if applicable) Admission Agreement See Licensing Progress Notes (CSD-513) CSD-699-Enrollment Information Attachment 4 Revised July 2005