Ariz. Admin. Code § R6-5-7405 - Complete Application; Initial License - New Applicant

A. A complete application package for an initial license of a new agency shall contain the information and supporting documentation listed in this subsection.

1. Identification and background information: agency, facility, administrators.

a. Name, address, and telephone and telefacsimile numbers for the agency and all facilities operated by the agency;

b. Name, title, business address, and telephone and telefacsimile numbers of:

i. The person who serves as the chief executive officer (CEO) as prescribed in R6-5-7432(A);

ii. The person who serves as the program director as prescribed in R6-5-7432(B);

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

iv. The person in charge of each separate facility as prescribed in R6-5-7432(C);

v. Persons holding at least a 10% ownership interest in the applicant; and

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

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

d. A list of the members of the agency's governing body described in R6-5-7424, including: name, address, position in the agency, term of membership, and any relationship to the applicant;

e. A list of licenses or certificates for provision of medical or social services, currently or previously held by the applicant or persons listed in subsection (A)(1)(b), including those held in this state or another state or country;

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 services, pending or filed, or brought against the applicant or a person listed in subsection (A)(1)(b), including those held in this state or another state or country; and

g. A written description of any litigation in which the applicant or a person listed in subsection (A)(1)(b) has been a party, including, without limitation, collection matters and bankruptcy proceedings during the 10 years preceding the date of application.

2. Business organization.

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

b. Business organization documents appropriate to the applicant, including:

i. Articles of incorporation, by-laws, annual reports for the preceding three years; or

ii. Partnership or joint venture agreement;

c. For corporations, a certificate of good standing from the Arizona Corporation Commission or comparable entity from a foreign state; and

d. A statement as to whether the applicant is for-profit or not-for-profit if not explained in other documents already provided.

3. Staff.

a. A list of the applicant's paid staff, including:

i. Name;

ii. Position or title;

iii. Degrees, certificates, or licenses held;

iii. Business address;

iv. Date of hire;

v. Date of last physical; and

vi. Date of submission for fingerprinting and background clearance;

b. Evidence that staff have submitted fingerprints and criminal background information, as prescribed in A.R.S. § 46-141 and R6-5-7431 and obtained a physical exam as prescribed in R6-5-7431(F); and

c. For any staff whose primary residence is the facility,

i. The name and date of birth of any persons residing with the staff member;

ii. Evidence that any adult residing with the staff member has submitted fingerprints and criminal background information as prescribed in R6-5-7431 and is free from communicable diseases posing a danger to children in care, as prescribed in R6-5-7431(H); and

iii. Evidence that the staff member's children who reside at the facility have current immunizations.

4. Financial Stability.

a. A written, proposed operating budget for start up and the first year of operation;

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 in accordance with 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;

e. If the applicant or one of the persons listed in subsection (A)(1)(b) has operated any child welfare agency in this state or any other state during the past 10 years, the most recent financial statement and financial audit for that agency, unless the most recent statement or audit is more than 10 years old; and

f. A certificate of insurance, or letter of commitment from an insurer, showing that the applicant has insurance coverage as prescribed in R6-5-7426.

5. Program.

a. Informational or advertising material about the agency and its facility;

b. For each facility, a written description of:

i. All services the applicant intends to provide;

ii. The number and type of children the applicant will serve, including: age, gender, special needs, or particular behavior problems;

iii. The anticipated sources of placement and referral;

iv. Number and qualifications of paid staff who will provide services, including the staff-child ratio, per living unit, during a 24-hour day, for a seven-day week; and

c. Program description, including:

i. Goals and objectives;

ii. Educational activities, with attached copy of Arizona Department of Education approval, if applicable;

iii. Recreational activities;

iv. Food and nutrition, with sample menus;

v. Behavior management practices;

vi. Religious practices, if any; and

vii. Medical services.

6. Documentation, Forms, and Notices. Samples of all documents, forms, and notices which the applicant will use with or provide to children placed with the agency, the parents and guardians of those children, and the persons and entities who place children, including:

a. Agency application for services;

b. Agency placement agreement;

c. Intake form;

d. Child's case file and medical record;

e. Forms for reports to courts and placing agencies;

f. Statement of client rights;

g. Unusual incident reports; and

h. Sample medication logs.

7. Policies and Procedures. The applicant's internal policies, procedures, and operations manual.

8. Physical site and environment.

a. The floor plan for each facility;

b. A DHS health and safety inspection report for each facility;

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

d. Fire safety inspection report from the state fire marshall or a local fire department inspector for each facility;

e. Any water supply report as prescribed in R6-5-7458(D);

f. Gas equipment inspection report as prescribed in R6-5-7465(D)(1); and

g. Any other inspection certificates or reports prescribed in this Article, and any building occupancy certificates.

9. Miscellaneous.

a. A statement authorizing the Department to investigate the applicant;

b. The signature, under penalty of perjury, of the agency administrator or person submitting the application, attesting to the truthfulness of the information contained in the application; and

c. The date of application.

B. If an applicant has attached a copy of a policy or procedure which describes the applicant's practice or procedure on a particular issue, the applicant need not separately describe the policy or procedure on the application form, but shall indicate that the description is contained in a particular identified and attached policy.

C. If the Licensing Authority needs additional information to determine the applicant's fitness to hold a license or an operating certificate, ability to perform the duties of a licensee as prescribed in this Article, or ability to fulfill the requirements prescribed in the applicant's policies, procedures, and program description, the Licensing Authority may require the applicant to provide additional information, including a signed form permitting a specifically named person or entity to release information to the Licensing Authority.

D. An agency which does not have or is unable to obtain all or part of the information or supporting documentation listed in subsection (A) shall so indicate in a written statement filed with the application. The written statement shall explain why the information or documentation is unavailable.

Notes

Ariz. Admin. Code § R6-5-7405

Adopted effective May 19, 1977 (Supp. 77-3). Former Section R6-5-7405 repealed; new Section R6-5-7405 filed with the Secretary of State's Office May 15, 1997; adopted effective July 1, 1997 (Supp. 97-2).