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CMS-07-021/023 - Los Angeles County Department of Children and ...

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Group Home Organization:<br />

FORMAT FOR BRIEF PROGRAM DESCRIPTION<br />

PER THE CONTRACT, SECTION 11.4<br />

EXHIBIT A-XII<br />

___________________________ _____________________________________<br />

Name Office Address<br />

_____________________ _____________________ _____________________<br />

Telephone Number Fax Number E-Mail Address<br />

_____________________ _____________________ _____________________<br />

RCL Level <strong>and</strong> Rate OR Regional Cntr Service Level & Rate L A <strong>County</strong> Vendor Number<br />

Site Information (each site):<br />

_____________________ _____________________ _____________________<br />

City & Zip Code (no street address) License Number Lic. Capacity, Sex, Age Range<br />

_____________________ _____________________ _____________________<br />

City & Zip Code (no street address) License Number Lic. Capacity, Sex, Age Range<br />

_____________________ _____________________ _____________________<br />

City & Zip Code (no street address) License Number Lic. Capacity, Sex, Age Range<br />

Target Population(s): [Include languages served, type(s) <strong>of</strong> children served (Severely<br />

or Seriously Emotionally Disturbed, severe behavioral problems, <strong>and</strong>/or<br />

Developmentally Disabled), <strong>and</strong> any special target populations as specified in the<br />

Agreement, Section 6.4(3).]<br />

______________________________________________________________________<br />

______________________________________________________________________<br />

______________________________________________________________________<br />

______________________________________________________________________<br />

______________________________________________________________________<br />

Accept <strong>Children</strong> Receiving Psychotropic Medications: Yes No<br />

Emergency Care (as described in the SOW, Part B, Section 4.0): Yes No<br />

On-Grounds School Available: Yes No<br />

Off-Grounds Non-Public School(s) Available: Yes No<br />

Ratio <strong>of</strong> Awake Supervision Staff to Placed <strong>Children</strong> for Each Shift: (Include all<br />

three shifts including weekdays <strong>and</strong> weekends.)<br />

_____________________ _____________________ _____________________<br />

Weekday A.M. Shift Weekday P.M. Shift Weekday Graveyard Shift<br />

_____________________ _____________________ _____________________<br />

Weekend A.M. Shift Weekend P.M. Shift Weekend Graveyard Shift

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