Arizona Administrative Code › Title 21 - CHILD SAFETY › Chapter 7 - DEPARTMENT OF CHILD SAFETY - CHILD WELFARE AGENCY LICENSING › Article 1 - LICENSING REQUIREMENTS FOR A CHILD WELFARE AGENCY › Section R21-7-107 - Child Welfare Agency Initial License Application Package

Current through Register Vol. 30, No. 28, July 12, 2024
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.