Bcal 1074 Form PDF Details

In an era where the safety, care, and developmental needs of children are paramount, the establishment and operation of child caring institutions take on a critical role. Key to this operation is the BCAL 1074 form, an essential document for anyone looking to establish or renew a child caring institution within certain jurisdictions. This comprehensive application encompasses a wide array of information requirements, starting from basic facility details to in-depth data regarding the applicant organization. Prospective operators must articulate not just the name and address of their institution, but also finer details about its capacity, the age and sex of the children it will serve, and the types of programs it will offer, among others. Moreover, it delves into whether the institution will operate under governmental or non-governmental auspices, specifies if it's a therapeutic group home or regular child caring institution, and even inquires about the presence of behavior management rooms. Beyond facility-specific information, the form requires applicant organizations to disclose legal and operational details, such as accreditation status, water and sewage systems, and staff criminal history checks, ensuring that only qualified entities are entrusted with the care of children. The insistence on thorough and accurate information underscores the form's role not just as a procedural hurdle, but as a guardian of standards in child care institutions, emphasizing safety, efficacy, and compliance with legal and ethical guidelines.

QuestionAnswer
Form NameBcal 1074 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesrehabilitative, T-Treatment, S-Short, BCAL

Form Preview Example

OR
Column 6.
Column 7.

INSTRUCTIONS FOR COMPLETING APPLICATION

FOR CHILD CARING INSTITUTION

FACILITY INFORMATION

1.Enter name of institution as it is to appear on the license or certificate of approval. 2 – 12. Enter appropriate information for the institution.

APPLICANT ORGANIZATION INFORMATION

13.Enter legal name under which the applicant organization is incorporated, or the governmental unit,

person, or partnership legally responsible.

14 – 21. Enter the appropriate information for the applicant.

22.Indicate destination where official licensing mail is to be directed.

24. Indicate if the auspices is governmental or non-governmental.

25. Check appropriate box.

26. TERMS INFORMATION: Regular CCI – any Non-Therapeutic Group Home. Therapeutic – 6 beds or less

– serving Developmentally Disabled or Seriously Emotionally Disturbed – No seclusion or restraints.

27.

Column 1.

Enter the name of the building, unit, wing, or floor of the facility which will house the

identified population.

 

 

 

Column 2.

Enter age range to be care for (Maximum age is 17).

 

 

Check male if only males are accepted or female if only females are accepted or

 

Column 3.

enter co-ed where the location is not limited to specific number of either males or

 

 

females.

 

 

• Open institution means an institution or facility, or portion thereof, which is used to

 

Column 4.

house residents and which is not locked against egress, except for an approved

 

 

behavior management room.

OR

• Secure institution means an institution or facility, or portion thereof, other than a

 

behavior management room, used to retain residents in custody. Outside doors

 

and individual sleeping rooms usually have locks preventing aggress from the

 

building.

 

OR

Column 5.

• Short-term institution means an institution which primarily provides care for

residents pending court action or other placement planning.

 

•Treatment institution means an institution whose primary purpose and function is to provide habilitative or rehabilitative services.

Enter capacity for the age range, sex, setting and program.

Indicate yes or no. A behavior management room means a room or areas approved by the department licensing authority for the confinement or retention of a resident. The door to the room may be equipped with a security locking device which operates by means of a key or is electrically operated and which has a key override and emergency electrical back up in case of a power failure.

28 – 39. Indicate yes or no or insert appropriate answer.

APPLICATION DECLARATION STATEMENT INFORMATION

40.Signature of individual authorized to make application on behalf of the Application Organization.

41.Enter title of person signing application.

42.Date Signed.

43 – 46. Enter the appropriate information for the person signing the application.

 

 

Department of Human Services (DHS) will not discriminate against any individual or group

AUTHORITY:

1973 PA 116

because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual

COMPLETION:

Is required.

orientation, gender identity or expression, political beliefs or disability. If you need help with

PENALTY:

Applicant cannot be licensed.

reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to

 

 

make your needs known to a DHS office in your area.

 

 

 

BCAL-1074 (Rev. 11-10) Previous editions obsolete. MS Word

CHILD CARING INSTITUTION APPLICATION

FOR DHS USE ONLY:

 

 

Michigan Department of Human Services

 

 

License Number

 

 

 

Zoning Code

 

 

(Follow Instructions on back of Application)

 

 

 

 

 

 

 

 

 

 

BCAL USE ONLY

 

Application is:

 

 

 

 

 

Paid Amount

Cashier

 

 

 

Original

 

 

 

Renewal

 

Change

 

 

 

 

 

 

 

 

FACILITY INFORMATION

 

 

 

 

 

 

APPLICANT ORGANIZATION INFORMATION

 

1.

Facility Name

 

 

 

 

 

 

 

 

 

 

 

 

13.

Organization Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Chief Administrator’s Name

 

 

 

 

 

 

 

 

 

14.

Applicant Representative

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Address (Street Number, Name, Suite, etc.)

 

 

 

 

 

 

15.

Address (Street Number, Name, Suite, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

City

 

 

 

 

5. State

 

6. Zip Code

 

16.

City

 

17.

State

18. Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Mailing Address (if different)

 

8. P.O. Box, City, State, Zip Code

 

19.

Mailing Address (if different)

20.

P.O. Box, City, State, Zip Code

 

P.O. Box

 

 

 

 

 

 

 

 

 

 

 

 

 

P.O. Box

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Telephone Number

 

 

 

 

10. County

 

 

 

 

 

21.

Telephone Number

22.

Direct Mail To

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

Organization

Facility

11. Township

12 Zoning Authority for Facility

 

 

 

 

 

23.

Federal ID Number

24.

Auspice Type

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-governmental

 

 

 

 

 

City/Village

Township

 

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Governmental

TERMS INFORMATION

 

25.

26. Regular Child Caring Institution

Therapeutic Group Home

 

 

 

 

Profit Non-Profit

County Federal

State Local

27. Terms Applied for

Age Range

 

 

Sex

 

Setting

Program

Capacity

Behavior

Location

(Max Age 17)

 

 

 

 

 

 

 

Mgmt.Rm.

A

 

 

 

 

 

Male

Co-ed

O-Open

S-Short Term

 

Y-Yes

 

 

 

 

 

Female

 

S-Secure

T-Treatment

 

N-No

FROM

 

 

TO

 

 

 

 

 

 

 

 

 

 

Male

Co-ed

O-Open

S-Short Term

Y-Yes

B

TO

Female

 

S-Secure

T-Treatment

N-No

FROM

 

 

 

 

 

 

 

 

 

Male

Co-ed

O-Open

S-Short Term

Y-Yes

C

TO

Female

 

S-Secure

T-Treatment

N-No

FROM

 

 

 

 

 

 

 

 

 

Male

Co-ed

O-Open

S-Short Term

Y-Yes

D

TO

Female

 

S-Secure

T-Treatment

N-No

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

Co-ed

O-Open

S-Short Term

Y-Yes

 

E

 

 

TO

 

 

Female

 

S-Secure

T-Treatment

N-No

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

28. Private Well

Yes

No

29. Private Sewer

Yes

No

30.TOTAL CAPACITY

31.

Is organization accredited?

Yes

No

32. By Whom?

 

 

 

 

33. Date of Accreditation:

34.

Was this specific facility visited by the accrediting body?

Yes

No

35. Is deemed status requested?

 

Yes

No

36.

Are there high adventure activities at this site?

Yes

No

37. Type:

Pool

Other Water

High Ropes

Low Ropes

 

 

 

 

 

 

 

 

Climbing Wall

Other – Specify

 

 

 

 

38. Have any staff been convicted of an offense for other than a minor traffic violation?

39. Will this facility serve community mental health funded children?

 

Yes

No

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICATION DECLARATION STATEMENT (Checked boxes confirm statements have been read)

I have read 1973 PA 116 or PA 280 and the Administrative Rules regulating the operation of the residential child caring facility indicated above and, if granted a license, certificate of approval, or certificate of inspection will endeavor to comply with the Act and these rules.

In order to permit a proper determination of conformity with the rules, I give permission to the Department of Human Services to make a necessary and reasonable investigation of my activities and proposed standards of care and to make an on-site evaluation of the proposed facility as described in Act

116.The investigation may include the securing of statements from references I submit, as well as from others who may make judgments as to my ability to comply with the rules.

I certify that the employees of this institution are of good moral character as required by administrative rules.

I hereby certify that any information I give in respect to this application and investigation will be, to the best of my ability, true and correct.

40. Authorized Signature

41. Title

42. Date

43. Address (Street Number and Name)

44. City

45. State

46. Zip Code

BCAL-1074 (Rev. 11-10) Previous editions obsolete. MS Word

1

DISTRIBUTION: When completed return to Licensing Consultant

 

 

Make a copy for your records

How to Edit Bcal 1074 Form Online for Free

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The right way to fill out S-Secure portion 1

2. After filling in the last section, go to the next step and fill out the essential particulars in all these blank fields - Location, FROM, FROM, FROM, FROM, FROM, Age Range Max Age , Yes, Private Well Is organization, Private Sewer, Yes, By Whom, Sex, Setting, and Program.

Private Sewer, Setting, and FROM of S-Secure

3. Completing I have read PA or PA and the, In order to permit a proper, I certify that the employees of, I hereby certify that any, Authorized Signature, Address Street Number and Name, Title, City, Date, State, Zip Code, BCAL Rev Previous editions, DISTRIBUTION When completed return, and Make a copy for your records is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Date, Authorized Signature, and State in S-Secure

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