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Effective Date: 
4/2019

Documents

 

Instructions

Updated: 12/2019

 

Purpose

These instructions apply only for completing Form 2960, Attachment C, General Residential Operations – Additional Operation Plan.

Form 2960-Attachment C is required for an applicant for a license to operate a general residential operation (GRO) that intends to provide treatment services to children with emotional disorders, and existing permit holders that request to amend a GRO license to add treatment services for children with emotional disorders.

 

Procedure

When to Prepare

Form 2960-Attachment C is a required part of the application process and should be used to develop and document the operational, community engagement and educational plan for the GRO. Licensing must approve the plan outlined on this form prior to accepting the application or amending the license.

Section A, Operation Information – Complete all fields in this section.

Section B, Community Engagement Plan  

  1. Provide a summary of the discussions you have had with local law enforcement about the prospective operation. – This section should include a summary of the discussions you have had with local law enforcement regarding the impact the prospective operation may have on the agency. If law enforcement officials express concerns about the impact the operation may have on community resources, you should include a summary of steps taken to address the concern(s) raised.
  2. Provide a summary of the discussions you have had with local health and therapeutic resources about the prospective operation. – This section should include a summary of the discussions you have had with each resource regarding the impact the prospective operation may have on the community. If local health or therapeutic resources express concerns about the impact the operation may have on community resources, you should include a summary of steps taken to address the concern(s) raised.
  3. Provide a summary of the discussions you have had with local recreational resources about the prospective operation. – This section should include a list of local recreational resources that will be available to children in care of the operation, and any additional recreational plans the operational will offer to children served by the operation.
  4. Describe the opportunities for social interaction within the community that will be available to children served by the operation. – Self-explanatory.
  5. Describe your plan to develop or improve relationships between the prospective operation and the local community. – This section should include efforts you will take to address any concerns raised within the community once the operation has opened.

Section C, Educational Plan – Complete all fields.

Section D, Trauma Informed Plan to Address Unauthorized Absences

Provide a summary of the operation’s trauma informed plan to address unauthorized absences from the operation. – This section should include a trauma informed proactive approach to prevent unauthorized absences from the operation, in addition to a trauma informed plan to address unauthorized absences from the operation.

Section E, Management and Leadership Professional History

Complete this section with information for each individual involved in the management or leadership role at the operation. If the operation provides educational services on-site, through a charter school, include information for the individual(s) in the educational leadership role at the operation. Complete each field:

Name – Enter the individual’s name.

Role at the operation – Enter the individual’s position.

Qualifications – Enter the individual’s professional qualifications to serve in the respective role at the operation.

Background – Enter the individual’s professional background as it relates to his or her role at the operation.

History in child care settings – Enter any history the individual has had in any child care settings, including the roles the individual held in each setting.

Compliance history in child care settings – List any corrective or adverse actions Licensing has taken against the previous operations in which the individual has worked, and the individual’s involvement in the action, if applicable.  

 

Transmittal

Applicants for a GRO that intend to provide treatment services to children with emotional disorders should include a completed copy of Form 2960-Attachment C, along with all other applicable application materials to the local Licensing office.

Existing permit holders of a GRO license that are requesting to amend the operation’s license, to include treatment services for children with emotional disorders, should send the completed copy of Form 2960-Attachment C, along with the request to amend the permit, to the Licensing inspector assigned to the operation.