PART A / licensing Forms

• Application (Lic 200)

• Applicant Information (Lic 215)

• Designation Of Administrative Responsibility (Lic 308)

• Administrative Organization (Lic 309)

• Affidavit Regarding Client Cash Resources (Lic 400)

• Surety Bond (Lic 402)

• Monthly Operating Statement (Lic 401)

• Supplemental Financial Information (Lic 401a)

• Balance Sheet Supplemental Schedule (Lic 403a)

• Balance Sheet (Lic 403)

• Financial Information Release & Verification (Lic404)

• Budget Information (Lic 420)

• Personnel Report (Lic 500)

• Personnel Record (Lic 501)

• Health Screening Report (Lic 503)

• Emergency Disaster Plan (Lic 610D)

• Covic-19 Mitigation Plan

• Residential Infection Control Plan

• Facility Sketch (Lic 999)

• Fire Inspection (Lic 9054)

• Board Of Director Statement (Lic 9165)

Part B / Program Design

• Partnership agreement/Articles Of Organization.

• Verification Of Administrator Qualifications & Certification.

• Plan Of Operation.

• Job Description.

• Personnel Policies.

• In-service Training For Staff.

• Facility Program Description.

• Rules Of Discipline/Personal Rights.

• Admission Policies.

• Sample Menu.

• Control Of Property.

• Neighborhood Complaint Policy.

• Admission Agreement.

• Emergency Information Plan.

• Needs & Service Plan.

• Emergency Intervention Plan

• Relocation Letters

• Activity Schedule

The Regional Center require that you submit the following:

• Application Form

• Disclosure Form

• Letter Of Intent

• Orientation Certificate

• Program Design

This program design is separate and distinct from the CCLD program design.

What I recommend to all of my clients is this: when we get a facility number assigned to the facility, submit a program design to Regional Center, this way both program designs will be going through the vetting process at the same time, and hopefully cross the finish line around the same time.

If you hire Mitchell & Mitchell to do your program design and corrections for Regional, the cost is $3,000.00. All program designs are in full compliance with HCBS final Rule.

Regional Center pay $11,719.45 a month for a level 4i client, but they only allow you to put one client in a bedroom. Hey, that’s $46,877.80 a month for 4 clients, $562,533.60 a year.