Ariz. Admin. Code § R21-7-107 - Child Welfare Agency Initial License Application Package

A. The applicant shall indicate on the application provided by the Department whether the applicant is applying for a Child Placing Agency license or a residential group care facility license, including a shelter care facility.

B. The applicant shall submit a complete application package that contains the information and supporting documentation listed in this Section.

1. Identification and background information for the agency, facility, and administrators, on an application provided by the Department:

a. Name, address, telephone number, and email addresses for the Agency and each facility operated by the agency;

b. Name, title, business address, and telephone number of:

i. The CEO described in R21-7-131 ;

ii. The Program Director described in R21-7-131 ;

iii. The person with delegated authority to act when the CEO is absent;

iv. The person designated to supervise the operations of each separate facility described in R21-7-131 ;

v. Any person holding ownership interest in the Agency; and

vi. The Agency and facility medical directors, if applicable;

c. The educational qualifications and work history for each person identified in subsection (B)(1)(b), with that person's attached resume, employment application containing a professional history, or curriculum vitae;

d. A list of the Agency's governing body described in R21-7-118 ;

e. A list of licenses or certificates for provision of medical or social services, currently or previously held by the applicant or any person listed in subsection (B)(1)(b), including those held in this state or another state or country, and the date the person held each license or certificate;

f. A written description of any proceedings for denial, suspension, or revocation of a license or certificate for provision of medical, psychological, behavioral health, or social or human services, pending or filed, or brought against the applicant or a person listed in subsection (B)(1)(b), including those held in this state or another state or country;

g. A written disclosure of civil and criminal court proceedings in which the applicant or a person listed in subsection (B)(1)(b) has been a party, including:

i. Lawsuits,

ii. Dependency actions including:

(1) Removal of a dependent,

(2) Voluntary relinquishment,

(3) Suspension of custody, or

(4) Termination of parental rights;

iii. Charges of child abuse or neglect;

iv. Child support enforcement proceedings within the last five years;

v. Bankruptcy within the last five years;

vi. Adoption; and

vii. Any other court proceedings; and

h. The licensing history of any individual detailed in R21-7-118(C) and person listed in subsection (B)(1)(b) if that person has ever applied to be certified or has been licensed in any state to provide care to a child or to a vulnerable adult.

2. Demonstration of Need, as described in R21-7-104(E)(2) . The applicant for a Child Welfare Agency license shall fill an unmet need in the community to serve children.

a. Describe the proposed geographical area, the target population, and demographics of the children it intends to serve; and

b. Demonstrate the ability to serve the proposed population.

3. Business organization

a. An organizational chart for the Agency and each separate facility, showing administrative structure, lines of authority, and staff;

b. Business organization documents appropriate to the applicant, as follows:

i. Corporate entities. An incorporated Child Welfare Agency shall provide the Department with a copy of the Articles of Incorporation, Bylaws, and the Certificate of Incorporation and Certificate of Good Standing issued by the Arizona Corporation Commission.

ii. A Limited Liability Company (LLC) shall provide the Department with a copy of the Articles of Organization and a Certificate of Good Standing issued by the Arizona Corporation Commission.

iii. A Partnership shall provide the Department with a copy of the Partnership Agreement and any other documents related to the Child Welfare Agency's formation and governance; and

c. A statement as to whether the applicant is for-profit or certified by the U.S. Internal Revenue Service (IRS) as not-for-profit and a copy of the IRS certification as a not for profit.

4. Staff

a. A list of the applicant's staff on the form provided by the Department.

b. Evidence that staff complies with A.R.S. § 46-141 and this Chapter.

c. For any staff whose primary residence is in the facility or on the premises under Article 2 of this Chapter include:

i. The name and date of birth of any person residing with a staff;

ii. Evidence that any adult residing with a staff at the facility or on the premises has an Arizona Level One fingerprint clearance card, a Central Registry Check, and the information required in R21-7-104 and R21-7-206 ;

iii. Evidence that any adult residing with a staff is free from communicable diseases posing a danger to children in care under R21-7-206 ;

iv. The custodial relationship between the staff and any child who resides on the premises; and

v. Evidence that any staff's child who resides on the premises has current immunizations based on the Centers for Disease Control and Prevention recommended immunization schedule.

5. Financial Stability

a. A certificate of insurance, or letter of commitment from an insurer, showing that the applicant has insurance coverage required by R21-7-128 ;

b. Verifiable documentation of funds available to pay start-up costs; the funds shall be in the form of cash or written authorization for a line of credit;

c. Verifiable documentation of funds available to pay operating expenses for the first three months of operations; the funds shall be in the form of cash or written authorization for a line of credit;

d. Verifiable documentation of financial resources to operate under the proposed operating budget for the remaining nine months of the licensing year. The resources may include:

i. Cash;

ii. Contracts for placement;

iii. Donations;

iv. Grants; and

v. Authorization for a line of credit; and

e. Resources shall not include:

i. Payday Loans;

ii. Title Loans; and

iii. Promises to pay without verifiable documentation of funds.

6. Program

a. Curriculum and materials, as related to the Agency's program.

b. Program description of the Agency's program and services addressing the following areas:

i. Goals and objectives;

ii. All services the applicant intends to provide;

iii. Any organization from which the applicant will seek accreditation;

iv. The demographics of the children the applicant plans to serve; and

v. The applicant's primary source of referrals, consistent with the applicant's demonstration of need.

c. The program description for a residential group care facility shall include the following areas:

i. For each facility, the number of children the applicant will serve, including the children's age, gender, special needs, or children with specific behavioral issues;

ii. A general description of the number and qualifications of the applicant's executive and direct care staff including the staff-child ratio per living unit, during a 24-hour day, for a seven-day week;

iii. Educational activities, including the form of on-campus educational programs the applicant will offer, and a copy of Arizona Department of Education and School District approval, if also operating a school;

iv. Recreational activities;

v. Food and nutrition, with sample menus;

vi. Behavior management practices;

vii. Religious practices;

viii. Medical services;

ix. The frequency and method by which the applicant will provide or offer psychiatric, psychological, or counseling services;

x. Whether the applicant will utilize the child in care's independent insurance; and

xi. Whether the applicant will employ or contract behavioral health practitioners; and

d. The program description shall indicate if any area specified in subsection (b) and (c) are not applicable.

7. Samples of all documents, forms, and notices that the applicant will use with or provide to children placed with or by the Agency, the parents and guardians of those children, and the persons and entities who place children.

8. A sample file the applicant will use for the personnel records required by R21-7-129, and the child in care's record as required by R21-7-121.

9. The applicant's internal policies, procedures, and operations manual.

10. Job description summary for all positions within the agency to include education and work experience required for each position.

11. Physical site and environment:

a. Documentation showing that the local zoning authority verifies that each Agency facility complies with all applicable zoning requirements;

b. Fire safety inspection report from the state fire marshal or a local fire department inspector for each facility when required by the local jurisdiction;

c. Any other inspection certificates, inspection reports, or building occupancy certificates required by the local jurisdiction.

d. Gas equipment inspection report for applicants under Article 2 of this Chapter.

12. A written plan for orientation and training for staff and includes a method for the agency to evaluate the staff's comprehension of the orientation and training and conforms to R21-7-132.

13. Miscellaneous:

a. The notarized signature of the Agency CEO or person submitting the application, attesting to the truthfulness of the information contained in the application; and

b. The date of application.

C. The applicant shall submit the Agency's policy and procedures.

D. The Department may require the applicant to provide additional information, including a signed form permitting a specifically named person or entity to release information to the Department, if any of the following applies:

1. To determine the applicant's fitness to hold a license or an operating certificate,

2. The ability to perform the duties of the licensee as prescribed in this Chapter, or

3. The ability to fulfill the requirements prescribed in the applicant's policy, procedure, and program description.

Notes

Ariz. Admin. Code § R21-7-107

New Section made by final rulemaking at 29 A.A.R. 2231, effective 11/6/2023.