STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PROGRAM CLASSIFICATION REPORT (SR 2)
CORPORATE NAME: PROGRAM NAME: PROGRAM NUMBER PROVIDER FISCAL YEAR
MO YR MO YR
(11)
(12)
(1)
CHILD CARE & SUPERVISION SOCIAL WORK ACTIVITIES MENTAL HEALTH ACTIVITIES
POINTS PER PROGRAM
90% OF
PER MONTH
LICENSED
(2) (3) (4) (5) (6) (7) (8) (9) (10)
RCL
PROGRAM CAPACITY
(COL. 4) + (COL. 7)
MONTH/YEAR
WEIGHTED POINTS
WEIGHTED POINTS WEIGHTED POINTS
HOURS HOURS (COL.9) ÷ (COL. 1)
(Minimum is 5.4)
HOURS HOURS (COL. 3)
÷ (COL. 1)
HOURS HOURS (COL. 6)
÷ (COL. 1)
+ (COL. 10)
MAXIMUM = 30
1. JANUARY __________
2. FEBRUARY __________
3. MARCH __________
4. APRIL __________
5. MAY __________
6. JUNE __________
7. JULY __________
8. AUGUST __________
9. SEPTEMBER __________
10. OCTOBER __________
11. NOVEMBER __________
12. DECEMBER __________
13. TOTAL
Maximum is 30
14. AVERAGE
15. DSS USE ONLY
Complete projected points and minimum RCL for the provider rate period for which the group home program will provide care and supervision. Refer to Section 11-402.562 (d) of Manual of Policies and Procedures regarding numbers projected
on Line 16 and how they will apply in the event of an audit adjustment.
16. PROJECTED
SR 2 (12/04)
PROGRAM CLASSIFICATION REPORT (SR 2)
PURPOSE:
The Program Classification Report (SR 2) establishes the rate classification level (RCL) for a group home program. The SR 2 captures historical or projected monthly data
regarding paid-awake hours (weighted and unweighted) of service to children in three program components: child care and supervision, social work activities and mental
health treatment services. The SR 2 is used to calculate points based on weighted hours of service for the reporting period and aids the group home provider and the
Department in determining the current and projected RCL for the group home program.
INSTRUCTIONS FOR COMPLETION:
Corporate Name: Enter the licensee/corporate name shown on the Group Home Program Rate Application (SR 1).
Program Name: Enter the program name, if any, shown on the SR 1.
Program Number: For an ongoing or “program change” application: enter number previously assigned by the Department. For an initial application: leave blank.
Reporting Period: Based on the provider’s fiscal year, enter the first month and its year through the last month and its year. Ongoing applications are based on the
provider’s previous fiscal year. The reporting period must be the same as that on the Group Home Program Days of Care Schedule (SR 5). Programs with less than twelve
months of operation should not enter data for a month prior to the effective date of the program. For an initial application, enter the proposed first month through twelfth month
of operation.
Month/Year: Lines 1 through 12 capture information for the reporting period.
EXAMPLES:
Partial reporting period is July 1 through December 31: complete columns on lines 7 through 12, indicating the provider’s previous fiscal year.
Full year reporting period is January 1 through December 31: complete lines 1 through 12, indicating the provider’s previous fiscal year.
Column 1 – 90% of Program Capacity, Minimum is 5.4
Calculate 90 percent of licensed capacity for the program. [Should correlate with Line 6 of the SR 5 for each month of the reporting period.] Enter result of calculation on
month-by-month lines for reporting period. For programs with no changes to licensed capacity, this number will stay the same throughout reporting period. Prorate licensed
capacity in months in which changes occur.
Enter 5.4 if ninety percent of licensed capacity is equal to or less than 5.4.
NOTE: In order to complete this form, preliminary work is necessary, i.e., the hours for each individual providing child care and supervision (CCS) must be gathered and
weighted for education and experience on a month-by-month basis. CCS staff may also receive weighting for all CCS hours if the group home program meets the
requirements of providing “on-going training”. Hours for each individual providing social work activities and mental health activities must also be gathered and
weighted according to the professional level of the individual providing the service. Worksheets have been developed by the Department for this purpose.
Substitute forms may also be used.
An explanation of how to weight hours is found in Manual of Policies and Procedures (MPP) Section 11-402.22.
Child Care and Supervision:
Column 2 – Hours: Enter the number of paid-awake hours for all individuals providing care and supervision, including hours of paid vacation or sick leave. Do not count
more than 54 regularly scheduled hours per week for an individual working in any program(s).
Column 3 – Weighted Hours: Enter the number of paid-awake hours for all individuals providing care and supervision which has been multiplied by the weighting for
experience, education and on-going training for those individuals.
Column 4 – Column 3 Divided by Column 1: Enter the result of dividing the weighted hours in column 3 by the 90 percent of licensed capacity in column 1. This result is
the points per child per month for the Child Care and Supervision component.
Social Work Activities:
Column 5 – Hours: Enter the number of hours for all social work professionals providing social work activities, including hours of paid vacation or sick leave. Do not count
more than 54 hours per week for an individual working in any program(s).
Column 6 – Weighted Hours: Enter the number of hours for all social work professionals providing social work activities which has been multiplied by the weighting for
professional level for those individuals.
Column 7 – Column 6 Divided by Column 1: Enter the result of dividing the weighted hours in column 6 by the 90 percent of licensed capacity in column 1. This result is
the points per child per month for the Social Work Activities component.
Mental Health Activities:
Column 8 – Hours: Enter the number of hours that all licensed mental health professionals provide direct service mental health activities to group home residents, either
individually or in groups.
Column 9 – Weighted Hours: Enter the number of hours that all licensed mental health professionals provide direct service mental health activities for group home
residents which has been multiplied by the weighting for professional level for those individuals. (NOTE: A program must report all mental health hours provided each
month under column 8. However a program may only multiply a maximum of 60 hrs by the appropriate weightings for any individual month under column 9. [See
MPP Section 11-402.234(c)]
Column 10 – Column 9 Divided by Column 1: Enter the result of dividing the weighted hours in column 9 by the 90 percent of licensed capacity in column 1. This result
is the points per child per month for the mental health activities component.
TOTALS:
Column 11 – Points Per Program Per Month: Enter the result of adding columns 4, 7, and 10.
Column 12 – RCL: Enter the two digit RCL indicated for the average and/or projected points per program per month.
Total, Average and Projected Lines:
Lines 13. Total: Enter the result of adding hours and weighted hours in each unshaded space.
Decimals should be entered using two decimal places (hundredths). Example: Calculation results in 220.32445: enter 220.32 on Line 13.
Line 14. Average: Enter the result of adding each column and dividing by the number of months reported.
Decimals should be entered using two decimal places (hundredths). Example: Calculation results in 220.32445: enter 220.32 on Line 14.
If Mental Health Activities points (Col. 10) are equal to or exceed 30, enter 30. Enter the two-digit rate classification level (1-14) based on the average points per program
per month during the reporting period.
Point Ranges RCL
Under 60 1
60-89 2
90-119 3
120-149 4
150-179 5
180-209 6
210-239 7
240-269 8
270-299 9
300-329 10
330-359 11
360-389 12
390-419 13
420 and up 14
** Line 16. Projected: Enter the projected numbers in unshaded spaces for the provider’s next fiscal year.
** A program must project the level of care and services provided in child care and supervision, social work activities and mental health treatment
services for the provider’s next fiscal year. Failure to provide projected numbers for the upcoming fiscal year will lead to a programs’ rate application
being classified as incomplete and subject to MPP Section 11-402.38.
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