Get Group Home Program Rate Application (sr 1) - California Department ... - Dss Cahwnet

Filling out the Group Home Program Rate Application (sr 1) is essential for organizations seeking funding or assistance for group home programs in California. This guide provides clear, step-by-step instructions to help you complete the application accurately and efficiently.

Follow the steps to successfully complete the application.

1. Press the ‘Get Form’ button to download the application form and open it in your chosen editor.
2. Begin by checking the appropriate box for the type of application at the top of the form. Options include ongoing, new provider, new program, program change, licensed capacity change, relocation, and reinstate.
3. Enter the proposed effective date, including the month and year.
4. In Line 1, provide the licensee or corporate name exactly as it appears on the group home license.
5. For Line 2, enter the program name, if applicable.
6. Enter the program number assigned by the Department in Line 3. For new applications, leave this blank.
7. Fill in the mailing address in Line 4, including the number and street.
8. In Line 5, provide the city name, followed by the state abbreviation in Line 5a and the zip code in Line 5b.
9. Continue to complete Lines 6 through 10 by entering the names and contact information for the executive director, approved administrator, contact person, agent for service, and board president.
10. In Lines 11 and 12, indicate the nonprofit status of the agency and whether it operates other businesses. If yes, specify the type of business in Line 13.
11. Indicate if the agency operates more than one group home program in Line 14 and provide the number of additional programs in Line 15.
12. Enter the total licensed capacity of the facilities used by the program in Line 16.
13. In the certification section, ensure the application is signed by the executive director or an authorized officer and complete Lines 17 to 20 with the necessary information.
14. Finally, review all entries for accuracy, save your changes, and prepare to download, print, or share the completed form.

Complete your application online today to ensure your group home program receives the necessary support.