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Home My WebLink AboutJACOB CENTER (703 PETERSON) - MODIFICATION OF STANDARD - 36-99 - CORRESPONDENCE - (3)CWS-52 (PAGE 3 OF 3 PAGES) SANITATION SURVEY. I, A DULY AUTHORIZED HEALTH OFFICER OF THE AREA IN WHICH THIS ESTABLISHMENT IS LOCATED, HEREBY CERTIFY THAT THE ABOVE PREMISES HAVE BEEN INSPECTED AND HAVE BEEN FOUND TO MEET THE REQUIREMENTS OFTHE COLORADO STATE DEPARTMENT OF PUBLIC HEALTH AND LOCAL REQUIREMENTS APPLICABLE TO THE OPERATION OF A SPECIALIZED GROUP HOME SIGNED - DATE TITLE DEPARTMENT ADDRESS COMMENTS - TOTAL NUMBER OF CHILDREN TO BE CARED FOR: AGE RANGE TYPE OF CHILDREN NUMBER OF BOYS: NUMBER OF GIRLS: NAME OF MSW SUPERVISOR _ WEEKLY SCHEDULE OF WORK WITH FACILITY FOR ORIGINAL APPLICATIONS, SUBMIT THE FOLLOWING: 1. STATEMENT OF PURPOSE AND FUNCTION- 2. WRITTEN POLICIES PURSUANT TO 7.709.21. 3. A DRAWING OF THE BUILDING WITH MEASUREMENTS OF ROOMS (NEED NOT BE A BLUEPRINT). IDENTIFY TOILET FACILITIES AND OUTDOOR PLAY SPACE 4. DESCRIBE THE SPECIALIZED SERVICES TO BE PROVIDED FOR CHILDREN AT THIS HOME AND WHO OR WHAT AGENCY WILL PROVIDE EACH SERVICE 5. DESCRIBE THE PLAN FOR PROVIDING THE FOLLOWING SERVICES FOR CHILDREN, SCHOOLING, RECREATION, MEDI- CAL, DENTAL, AND OPTICAL CARE 6. STATEMENT FROM LOCAL ZONING DEPARTMENT WHICH INDICATES PROPER ZONING. FOR RENEWAL AND ORIGINAL APPLICATIONS SUBMIT. (DO NOT INCLUDE ITEMS FOR NUMBERS 7, 8, OR 9 IF PREVIOUSLY SUBMITTED.) 7. DOCUMENTATION OF EDUCATION AND EXPERIENCE OF MSW SUPERVISOR 8. COPY OF MEDICAL STATEMENT, REFERENCE STATEMENTS, DOCUMENTATION OF EDUCATION AND EXPERIENCE FOR PRIMARY CAREGIVER AND EACH STAFF MEMBER OF HOME OR CENTER 9. COPY OF STATEMENT FROM A CERTIFIED PSYCHOLOGIST, PSYCHIATRIST, OR LICENSED SOCIAL WORKER 11 REGARD- ING THE PRIMARY CAREGIVER IF NOT PREVIOUSLY SUBMITTED. 10. WRITTEN AND DATED DOCUMENTATION THATAN ONSITE HOME INSPECTION HAS BEEN MADE AND THE FACILITY IS IN COMPLIANCE WITH THE MINIMUM RULES AND REGULATIONS FOR SPECIALIZED GROUP FACILITIES. FOR RENEWAL APPLICATIONS. DESCRIBE CHANGES IN ANY OF THE FIRST SIX ITEMS. EFFECTIVE OCTOBER 1, 1990, THE FEES FOR BOTH ORIGINAL AND RENEWAL APPLICATIONS (INCLUDING THE RENEWAL OF PROVISIONAL LICENSES) ARE AS FOLLOWS: Child Careenters(including Residential and Other Group Facilities: Licensed capacity of 5 to 12 chitdten._------•----...._._530.00 Licensed capacity of 13 to 30 children_-- ......................-..W.00 Licensed opacity of 31 to 50 children-•---------......._.._._350 00 Licensed opacity of 51 to 70 children................................560.00 Licensed capacity of 71 to 90 children-_._._ .................. -.470.00 Licensed capacity over 90 children ...... _........................... 580.00 If you have questions• please call our Child Care Information Specialist at (303) 866-5958. MAIL TO: COLORADO DEPARTMENT OF SOCIAL SERVICES 1575 SHERMAN STREET DENVER, COLORADO 80203 ATTENTION: LICENSING CWS-52 (PAGE 2 OF 3 PACESI LIST BELOW ALL PERSONS LIVING IN THE SPECIALIZED GROUP FACILITY, INCLUDING PRIMARY CAREGIVER, SPOUSE,; CAREGIVER'S CHILDREN, RELATIVES, ROOMMATES, BOARDERS. (DO NOT INCLUDE NAMES OF FOSTER CHILDREN.) _ FULL NAME SOCIAL SECURITY NO. BIRTH DATE OCCUPATION OR SCHOOL GRADE COMPLETED RELATION- SHIP DATE OF LAST MEDICAL ADULTS OTHER THAN APPLICANT LIVING IN THE HOME MUST SIGN AND HAVE NOTARIZED THE STATEMENT BELOW. I HEREBY AUTHORIZE THE COLORADO DEPARTMENT OF SOCIAL SERVICES, LICENSING SECTION, TO REVIEW MY NAME WITH THE STATE CENTRAL REGISTRY OF CHILD PROTECTION AND OBTAIN REPORTS OF CHILD ABUSE AND NEGLECT. PRINT FULL NAME SIGNATURE BIRTH DATE ADDRESS SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF MY COMMISSION EXPIRES NOTARY ADDRESS 19 19 HAVE YOU, ANYONE LIVING WITH YOU, OR ANYONE EMPLOYED BY YOU BEEN CONVICTED OF ANY FELONY, CHILD ABUSE, OR AN UNLAWFUL SEXUAL OFFENSE? YES_ NO IF YES, NAME OF PERSON BIRTH DATE NAME AT TIME OF CONVICTION IF DIFFERENT TYPE OF CONVICTION DATE OF CONVICTION IN WHAT TOWN, COUNTY, STATE DID THE CONVICTION OCCUR? (TOWN) (COUNTY) (STATE) APPROVALS (FOR ORIGINAL APPLICATIONS ONLY) SAFETY FROM FIRE HAZARDS. I HEREBY CERTIFY THAT THE ABOVE PREMISES HAVE BEEN INSPECTED BY AN AUTHORIZED REPRESENTATIVE OF THE LOCAL FIRE DEPARTMENT AND HAVE BEEN FOUND TO MEET THE REQUIREMENTS OF LOCAL FIRE REGULATIONS APPLICABLE TO THE OPERATION OF A SPECIALIZED GROUP HOME SIGNED DATE TITLE DEPARTMENT ADDRESS COMMENTS �I F COLORADO DEPARTMENT OF SOCIAL SERVICES CWS-52 (REV. 1/87) (PAGE I OF 3 PAGES APPLICATION FOR LICENSE -SPECIALIZED GROUP FACILITY ( )RENEWAL ( ) SPECIALIZED GROUP HOME ( ) SPECIALIZED GROUP CENTER ID NUMBER NAME OF SPECIALIZED GROUP FACILITY SCHOOL DISTRICT NO. TELEPHONE NO. LOCATION ADDRESS ZIP COUNTY LEGAL NAME OF THE SPONSORING OR SUPERVISING AGENCY, PRIVATE PLACEMENT AGENCY OR COUNTY DEPARTMENT OF SOCIAL SERVICES MAILING ADDRESS CITY ZIP TELEPHONE NO. LEGAL NAME 8 STREET ADDRESS OF GOVERNING BODY OF RAILING ADDRESS: CITY ZIP FEDERAL EMP. TAX 10 NO, SPECIALIZED GROUP CENTER ATTACH LIST OF NAMES AND ADDRESSES OF MEMBERS OF BOARD OF DIRECTORS AND OFFICERS OF THE GOVERN. ING BODY. THE UNDERSIGNED HEREBY APPLIES FORA LICENSE TO OPERATE A CHILD CARE CENTER-24=HOUR CARE UNDER 26-6- 101 ET. SEQ. C.R.S. 1982 AS AMENDED, AND CERTIFIES TO THE FOLLOWING FACTS: 1. 1 HAVE READ AND AM FULLY FAMILIAR WITH THE MINIMUM RULES AND REGULATIONS FOR SPECIALIZED GROUP HOMES, ISSUED BY THE COLORADO DEPARTMENT OF SOCIAL SERVICES, AND I AGREE TO FULLY COMPLY WITH THEM. 2. I UNDERSTAND THAT BEFORE A LICENSE CAN BE ISSUED AN INVESTIGATION MUST BE COMPLETED AND I SHALL ' COOPERATE WITH THE DEPARTMENT OF SOCIAL SERVICES TO DETERMINE CONFORMITY WITH THE REGULATIONS. 3. 1 AM AWARE THAT IF ISSUED A LICENSE IT IS TIME -LIMITED AND WILL DESIGNATE THE NUMBER AND AGE OF UNRELATED CHILDREN FOR WHICH CARE MAY BE GIVEN AT THIS FACILITY. FURTHER, I UNDERSTAND THAT IF 1 FAIL TO MAINTAIN THE RULES AND REGULATIONS THE LICENSE IS SUBJECT TO REVOCATION. 1 4. 1 HEREBY GIVE AUTHORIZATION TO THE DEPARTMENT TO OBTAIN REPORTS OF CHILD ABUSE OR NEGLECT OR TO j REVIEW THE STATE CENTRAL REGISTRY OF CHILD PROTECTION FOR THE APPLICANT. APPLICANTS SHALL SIGN FOR THEIR MINOR CHILDREN LIVING IN THE CHILD CARE FACILITY. 5. 1 UNDERSTAND THAT THE APPLICANT, DIRECTOR OF AGENCY, OR ANY PERSON WHO RESIDES IN THE CHILD CARE I FACILITY MAY BE REQUIRED TO SUBMIT A COMPLETE SET OF FINGERPRINTS TO THE COLORADO BUREAU OF INVES- TIGATION, AND ALL COSTS SHALL BE BORNE BY THE APPLICANT, DIRECTOR, OR PERSON WHO RESIDES IN THE CHILD CARE FACILITY. 6.ANY INFORMATION GIVEN IN THE QUESTIONS WHICH FOLLOW SHALL BE CORRECT TO THE BEST OF MY ABILITY. SIGNATURE OF AGENCY OR DEPARTMENT OFFICIAL PRINT NAME DATE SIGNATURE OF FACILITY PARENT(S) OR PERSONNEL PRIMARILY RESPONSIBLE FOR CHILD CARE - PRIMARY CAREGIVER(S) PRINT NAME OF PRIMARY CAREGIVER SIGNATURE HAS THE PRIMARY CAREGIVER EVER APPLIED FOR A LICENSE FOR CHILD CARE BEFORE? ( ) YES I ) NO IF SO, WHEN AND WHAT TYPE? NA FKIMAHY CAREGIVERS NAME AND ADDRESS THE SAME? DF NOT. WHAT WAS IT') 1 IYES ( INO WAS LICENSE DENIED? IF SO. GIVE DETAILS. 1 ) YES I ) NO C W S-52 41.87 394.25.18-5202 Jacob Family Services Licensed Child Placement Agency September 14, 1999 Troy W. Jones City Planner Jacob Center North Current Planning Department 633 Remington Street 281 North College Avenue Fort Collins, 8osza (970)484-8427 Fort Collins, Colorado 80522-0580 27 Fax: 482-8713 RE: 703 Peterson Group Home Proposal. Jacob Center Fast 1116 9th Street Greeley, CO 80631 (970) 352-2852 Fax: 3524428 Jacob Center Longmont 380 Main Street #221 Longmont, CO 80501 (303) 774-9837 Fax: 774-9837 Dear Troy: I am writing you in response to your phone message today regarding our proposal to change the use of 703 Peterson from a Foster Home to a Group Home. The Foster Home currently serves 4 young adults. We are requesting it be changed to a Group Home that would serve 6-8 young adults. There are no changes in the services that are provided to the young adults in placement. A copy of the Group Home application is enclosed. The Lot size is 84 feet by 146 feet, 12,264 square feet. There are two rooms up stairs; 11.5 feet x 12 feet, 138 square feet and 11.5 feet x 14 feet, 161 square feet. There are two bedrooms down stairs; 12 feet x 20.7 feet, 248 square feet and 9.9 feet x 18.4 feet, 182 square feet. There is a 1/2 bathroom upstairs and two full bathrooms down stairs. We have no plans to structurally change the building on the outside or inside in any way. The house will remain the same with the exception of routine maintenance. There is one other group come on Mathews Street but it is riot within the 1000. We had the City Planning measured this out about one year ago. I would like to participate in the neighborhood meeting on Monday October 1 lth if possible. If there is any other information that I can provide for you please feel free to contact me at 484-8427. 1 look forward to hearing from you on the scheduled date for the neighborhood meeting. Thank you for your ' ee, 1 J ?1D. inter M.A. A III CRC Program Director