Form Bcal 1609 PDF Details

The BCAL 1609 form serves a pivotal role within the Michigan Department of Human Services, particularly under the Bureau of Children and Adult Licensing. Created to ensure that facilities dedicated to providing specialized programs to individuals with mental illnesses and/or developmental disabilities operate under strict compliance, this form acts as a comprehensive certification application. Facilities seeking to either initiate or modify their certification must navigate through various sections capturing essential details from facility information, licensee data, to descriptions of the specialized programs offered. The form intricately outlines the requirement for facilities to cater to the specified populations, as authorized by their Adult Foster Care (AFC) License, emphasizing a stringent adherence to the Mental Health Code and relevant administrative rules. It mandates facilities to accurately report their current operations, including staffing ratios and the nature of the specialized services provided, ensuring that all information is true to the best of the applicant’s knowledge. Importantly, the BCAL 1609 also embodies a commitment to nondiscrimination, aligning with broader societal values of inclusivity and equality. By certifying that they meet these detailed stipulations, facilities contribute to a regulated environment where individuals with mental illnesses and developmental disabilities receive appropriate, high-quality care.

QuestionAnswer
Form NameForm Bcal 1609
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names1974, DHS, Designee, developmentally

Form Preview Example

CERTIFICATION OF SPECIALIZED PROGRAMS

APPLICATION FOR CERTIFICATION

Michigan Department of Human Services

Bureau of Children and Adult Licensing

SECTION I – FACILITY INFORMATION

FOR DHS USE ONLY – Cashier code: 41

License Number:

Paid Amount:

Cashier:

1.

Type of Application:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INITIAL

MODIFICATION: Specify Change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effective Date of Change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Certificate Type (Population served must be mentally ill and/or developmentally disable as authorized by AFC License.)

 

 

MENTAL ILLNESS

DEVELOPMENTAL DISABILITY

 

MENTAL ILLNESS & DEVELOPMENTAL DISABILITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Facility Name

 

 

4.

Facility Street Address

 

 

 

5. Facility City, State, Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Area Code/Telephone Number

 

 

7. Area Code/Fax Number

 

 

8. Email Address (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Facility Mailing Address (if different than #4)

 

 

 

 

10.

County

 

 

11. Township

 

 

 

 

 

 

 

 

 

 

 

 

12.

AFC License Number

13. AFC Expiration Date

14. Licensed Capacity

 

 

15. Current Occupancy

 

 

 

 

 

 

 

 

 

 

 

 

 

16.

Number of individuals residing in the facility for whom you receive specialized compensation.

 

 

 

 

 

 

 

Persons with

 

 

 

 

Persons with Developmental

 

Persons with Mental Illness and

 

 

 

Mental Illness

 

 

 

 

Disability(ies)

 

 

 

 

Developmental Disability(ies)

 

 

 

 

 

 

 

 

SECTION II – ADULT FOSTER CARE LICENSEE INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17.

Name of Licensee

 

 

 

 

 

 

 

18.

Licensee Designee (if applicable)

 

 

 

 

 

 

 

 

19.

Street Address

 

20.

City, State, Zip Code

 

 

 

21. Mailing Address (if different than #19)

 

 

 

 

 

 

 

 

22.

Area Code/Telephone Number

 

 

23. Area Code/Fax Number

 

 

24. Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION III – PLACING AGENCY INFORMATION (Attach additional sheets as necessary)

25.

Agency Name

 

 

26. Contact Person

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27.

Street Address

28. City, State, Zip Code

 

29.

Mailing Address (if different than #27)

 

 

 

 

 

 

 

 

 

 

 

 

30.

Area Code/Telephone Number

31. Area Code/Fax Number

 

32.

Email Address

 

 

 

 

 

 

 

 

 

 

 

SECTION IV – STAFFING INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33.

Staff-to-resident ratio on each shift:

 

 

 

 

 

 

 

 

 

A.M. Shift:

P.M. Shift:

MIDNIGHT Shift:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BCAL-1609 (Rev. 2-13) Previous editions obsolete. MS Word

1

SECTION V – DESCRIPTION OF SPECIALIZED PROGRAM(S) PROVIDED

34. Specialized Program Description (Attach additional sheets if necessary)

SECTION VI – CERTIFICATION AND SIGNATURE

The applicant certified that the relevant provisions of 1974 PA 258, as amended (Mental Health Code), the Administrative Rules (330.1801 through 330.1809), and relevant portions of the 1985 Life Safety Code, Appendix F, which regulate the operation of Specialized Programs Offered to Persons with Mental Illness or Developmental Disability(ies) have been read.

The applicant certifies that the information contained in this application is true, complete and accurate to the best of the applicant’s knowledge.

35. Adult Foster Care Licensee Name (print or type)

36. Licensee or Licensee Designee Signature

37. Date Signed

 

 

 

Authority:

1979 PA 218

 

1974 PA 258

Completion:

Mandatory

Penalty:

Certification will not be issued.

Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with 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-1609 (Rev. 2-13) Previous editions obsolete. MS Word

2

How to Edit Form Bcal 1609 Online for Free

You could complete ies without difficulty by using our PDFinity® editor. The editor is constantly maintained by our staff, acquiring handy functions and growing to be greater. This is what you'd want to do to start:

Step 1: Open the PDF doc in our editor by clicking the "Get Form Button" in the top section of this webpage.

Step 2: As soon as you access the online editor, you will get the document all set to be filled in. Besides filling out different blanks, it's also possible to perform some other things with the PDF, specifically writing any textual content, modifying the original text, inserting illustrations or photos, signing the PDF, and much more.

This document will require specific data to be typed in, therefore be sure you take your time to type in what is asked:

1. While completing the ies, make certain to include all important blanks within its relevant area. It will help to expedite the process, enabling your information to be processed promptly and correctly.

How to fill in certifies stage 1

2. Once the last section is done, you're ready include the required specifics in AFC License Number, AFC Expiration Date, Licensed Capacity, Current Occupancy, Number of individuals residing in, Persons with Mental Illness, Persons with Developmental, Persons with Mental Illness and, Disabilityies, Developmental Disabilityies, SECTION II ADULT FOSTER CARE, Name of Licensee, Street Address, Licensee Designee if applicable, and City State Zip Code so you're able to proceed to the third step.

Simple tips to prepare certifies part 2

3. In this specific part, examine Stafftoresident ratio on each, AM Shift, PM Shift, MIDNIGHT Shift, and BCAL Rev Previous editions. All these are required to be filled in with highest focus on detail.

BCAL Rev Previous editions, MIDNIGHT Shift, and PM Shift of certifies

4. This next section requires some additional information. Ensure you complete all the necessary fields - Specialized Program Description - to proceed further in your process!

certifies conclusion process shown (part 4)

5. The last step to submit this PDF form is crucial. You'll want to fill in the displayed form fields, and this includes The applicant certified that the, Licensee or Licensee Designee, Date Signed, Authority, PA PA, Completion Mandatory, Penalty, Certification will not be issued, Department of Human Services DHS, and BCAL Rev Previous editions, before using the pdf. Failing to do this may give you an incomplete and possibly invalid document!

Filling out part 5 of certifies

People who work with this form often make errors when completing The applicant certified that the in this area. You need to reread everything you type in right here.

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