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Home My WebLink About32357-Agreement No. 16-031 Children's ('.=dical Services Plan and FiscCGuidelines COUNTY: Fresno FISCAL YEAR: 2015-16 Plan and Budget Required Documents Checklist MODIFIED FY 2015-16 Document 1. Checklist 2. Agency Information Sheet 3. Certification Statements A Certification Statement (CHOP)-Original and one photocopy B. Certification Statement (CCS) -Original and one photocopy 4. Agency Description A Brief Narrative B. Organizational Charts for CCS, CHOP, and HCPCFC C. CCS Staffing Standards Profile D. Incumbent Lists for CCS, CHOP, and HCPCFC E. Civil Service Classification Statements-Include if newly established, proposed, or revised F. Duty Statements-Include if newly established, proposed, or revised 5. Implementation of Performance Measures 6. Data Forms A. CCS Caseload Summary B. CHOP Program Referral Data 7. Memoranda of Understanding and ln~eragency Agreements List A MOU/IAA List B. New, Renewed, or Revised MOU or IAA C. CHOP IAA with DSS biennially D. Interdepartmental MOU for HCPCFC biennially 8. Budgets A. CHOP Administrative Budget (No County/City Match) 1. 2. 3. Budget Summary Budget Worksheet Budget Justification Narrative Page Number 1 3 4 5 Retain locally Retain locally 6, 11,13 N/A N/A 14 40 41 43 44,46 Retain locally Retain locally 62 63 65 Children's Udical Services Plan and Fiscr:Guidelines COUNTY: Fresno FISCAL YEAR: 2015-16 Certification Statement-Child Health and Disability Prevention (CHOP) Program County/City: Fresno/Fresno Fiscal Year: 2015-16 I certify that the CHOP Program will comply with all applicable provisions of Health and Safety Code, Division 106, Part 2, Chapter 3, Article 6 (commencing with Section 124025), Welfare and Institutions Code, Division 9, Part 3, Chapters 7 and 8 (commencing with Section 14000 and 14200), Welfare and Institutions Code Section 16970, and any applicable rules or regulations promulgated by DHCS pursuant to that Article, those Chapters, and that section. I further certify that this CHOP Program will comply with the Children's Medical Services Plan and Fiscal Guidelines Manual, including but not limited to, Section 9 Federal Financial Participation. I further certify that this CHOP Program will comply with all federal laws and regulations governing and regulating recipients of funds granted to states for medical assistance pursuant to Title XIX of the Social Security Act (42 U.S. C. Section 1396 et seq.). I further agree that this CHOP Program may be subject to all sanctions or other remedies applicable if this CHOP Program violates any of the above laws, regulations and policies with which it has certified it will comply. \ -'+ -{(p oa?e S){ned Signature and Title of Other-Optional Date Signed I certify that this plan has been approved by the local governing body. Signature of Local Governing Body Chairperson ATTEST: BERNICE E. SEIDEL, Clerk Board of Supervisors By~~ ~sb2'P Deputy I-!A7-ILP Date 3 Children's Gdical Services Plan and FiscOuidelines COUNTY: Fresno FISCAL YEAR: 2015-16 Certification Statement-California Children's Services (CCS) County/City: Fresno/Fresno Fiscal Year: 2015-16 I certify that the CCS Program will comply with all applicable provisions of Health and Safety Code, Division 106, Part 2, Chapter 3, Article 5, (commencing with Section 123800) and Chapters 7 and 8 of the Welfare and Institutions Code (commencing with Sections 14000- 14200), and any applicable rules or regulations promulgated by DHCS pursuant to this article and these Chapters. I further certify that this CCS Program will comply with the Children's Medical Services Plan and Fiscal Guidelines Manual, including but not limited to, Section 9 Federal Financial Participation. I further certify that this CCS Program will comply with all federal laws and regulations governing and regulating recipients of funds granted to states for medical assistance pursuant to Title XIX of the Social Security Act (42 U.S.C. Section 1396 et seq.) and recipients of funds allotted to states for the Maternal and Chilc;l Health Services Block Grant pursuant to Title V of the Social Security Act (42 U.S.C. Section 7·01 et seq.). I further agree that this CCS Program may be subject to all sanctions or other remedies applicable if this CCS Program violates any of the above laws, regulations and policies vvith which it has certified it will comply. Signature and Title of Other-Optional Date Signed I certify that this plan has been approved by the local governing body. Signature of Local Governing Body Chairperson ATTEST: BERNICE E. SEIDEL, Clerk Board of Supervisors By Sus.D-M &sbaf Deput I· d.l ·I Lo Date Signed 4 Children's Udical Services Plan and Fiscr:Guidelines COUNTY: Fresno FISCAL YEAR: 2015-16 Certification Statement-Child Health and Disability Prevention (CHOP) Program County/City: Fresno/Fresno Fiscal Year: 2015-16 I certify that the CHOP Program will comply with all applicable provisions of Health and Safety Code, Division 106, Part 2, Chapter 3, Article 6 (commencing with Section 124025), Welfare and Institutions Code, Division 9, Part 3, Chapters 7 and 8 (commencing with Section 14000 and 14200), Welfare and Institutions Code Section 16970, and any applicable rules or regulations promulgated by DHCS pursuant to that Article, those Chapters, and that section. I further certify that this CHOP Program will comply with the Children's Medical Services Plan and Fiscal Guidelines Manual, including but not limited to, Section 9 Federal Financial Participation. I further certify that this CHOP Program will comply with all federal laws and regulations governing and regulating recipients of funds granted to states for medical assistance pursuant to Title XIX of the Social Security Act (42 U.S. C. Section 1396 et seq.). I further agree that this CHOP Program may be subject to all sanctions or other remedies applicable if this CHOP Program violates any of the above laws, regulations and policies with which it has certified it will comply. \ -'+ -{(p oa?e S){ned Signature and Title of Other-Optional Date Signed I certify that this plan has been approved by the local governing body. Signature of Local Governing Body Chairperson ATTEST: BERNICE E. SEIDEL, Clerk Board of Supervisors By~~ ~sb2'P Deputy I-!A7-ILP Date 3 Children's Gdical Services Plan and FiscOuidelines COUNTY: Fresno FISCAL YEAR: 2015-16 Certification Statement-California Children's Services (CCS) County/City: Fresno/Fresno Fiscal Year: 2015-16 I certify that the CCS Program will comply with all applicable provisions of Health and Safety Code, Division 106, Part 2, Chapter 3, Article 5, (commencing with Section 123800) and Chapters 7 and 8 of the Welfare and Institutions Code (commencing with Sections 14000- 14200), and any applicable rules or regulations promulgated by DHCS pursuant to this article and these Chapters. I further certify that this CCS Program will comply with the Children's Medical Services Plan and Fiscal Guidelines Manual, including but not limited to, Section 9 Federal Financial Participation. I further certify that this CCS Program will comply with all federal laws and regulations governing and regulating recipients of funds granted to states for medical assistance pursuant to Title XIX of the Social Security Act (42 U.S.C. Section 1396 et seq.) and recipients of funds allotted to states for the Maternal and Chilc;l Health Services Block Grant pursuant to Title V of the Social Security Act (42 U.S.C. Section 7·01 et seq.). I further agree that this CCS Program may be subject to all sanctions or other remedies applicable if this CCS Program violates any of the above laws, regulations and policies vvith which it has certified it will comply. Signature and Title of Other-Optional Date Signed I certify that this plan has been approved by the local governing body. Signature of Local Governing Body Chairperson ATTEST: BERNICE E. SEIDEL, Clerk Board of Supervisors By Sus.D-M &sbaf Deput I· d.l ·I Lo Date Signed 4