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DEPARTMENT OF SOCIAL SERVICES

LICENSE EXEMPT RESIDENTIAL CARE FACILITY NOTIFICATION

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RESIDENTIAL CARE FACILITY INFORMATION

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RESIDENTIAL CARE FACILITY STAFF INFORMATION

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FACILITY CONTACT

TYPE OF AGENCY

OPERATING AGENCY OR ORGANIZATION INFORMATION

SPONSORING ORGANIZATION INFORMATION

SUPPLEMENTAL DOCUMENTS - If No or Not Required, please provide detailed statement regarding reason certificates not provided

List of all staff members, volunteers, and any individual eighteen (18) years or older who reside at or on the property of the residential care facility (attach additional pages if necessary) at this time of this Notification being filed.

 

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and attestation on behalf of the notifying entity and that the information contained in the Notice and the supporting materials are true, accurate, and complete. I hereby further attest and affirm that the facility actually maintains medical records for each child served by the facility according to the written policy of the facility, a copy of which is submitted as supporting materials to this Notification.

I further certify, under oath and subject to penalty of perjury, that all individuals who are required to successfully complete background checks pursuant to section 210.493 RSMo and 13 CSR 35-71.015, 13 CSR 35-71.300, have completed background checks or will have completed background checks by the end of the phase-in period, unless an extension has been granted by the Division, and are eligible as provided by law.

    Thank You

    Dear {formsubmittinguser},

    Thank you for your Notification submission to the Missouri Department of Social Services.

    In accordance with the Residential Care Facility Notification Act, upon conclusion of the phase in period, the Notification process is not complete until all documentation has been reviewed and verified for compliance, and upon all officers, managers, contractors, volunteers with access to children, owners with access to facilities, employees and other support staff have successfully completed the background check process. Please instruct all required personnel listed on the Notification to begin the background check process at: (link)

    If you have questions regarding background checks, please email CD.Screen@dss.mo.gov.

    If you have questions regarding the notification process, please email CD.Notify@dss.mo.gov.

    If you have questions or need to check the status of your Notification, please contact the Residential Program Unit at (573) 751-4954. Your submission number is {formuniqueid}.

    Sincerely,
    Missouri Department of Social Services, Residential Program Unit