Any individual, group or organization requesting consideration for a license as a community home shall submit information to PSD, as described in Subsections A-F of this Section. The application shall include:

1. A. Description and organization: Each applicant community home shall provide PSD a description of the community home to include, but not limited to:

   (1) the name or proposed name and location of the community home;

   (2) statement of non-profit status;

   (3) names and addresses of the members of the governing board;

   (4) name and address of the community home’s administrator; and

   (5) a signed statement from the community home administrator acknowledging responsibility for:

   (a) providing for the safety and well-being of children placed in the community home;

   (b) monitoring risks that may expose the organization to liability; and

   (c) monitoring risks that may reveal unsatisfactory service.

2. B. Statement of purpose, including:

   (1) philosophy of the applicant community home;

   (2) the type of services to be provided to children placed in the community home;

   (3) the type of services that may be offered to children outside of the community home; and

   (4) any applicable and current accreditations or affiliations.

3. C. Personnel:

   (1) Applicant community homes will list the name of the supervisor and the home’s administrator, such as the chief executive officer, the executive director, or the individual responsible for the administration of the community home.

   (2) The applicant community home shall in its application provide the following information regarding staff and contract providers:

   (a) name, telephone and address of parent company and any contract providers, if applicable.

   (b) practicing clinical staff resumes, copy of current professional licensure, if applicable;

   (c) staff criminal records checks and abuse and neglect checks results; and

   (d) organizational charts.

4. D. Policies and procedures: Community homes shall develop policies and procedures that address the health and safety of children as outlined in Section 16 of 8.26.6 NMAC.

5. E. Community home operations: The applicant community home shall include documentation of financial operations, including:

   (1) a statement of financial responsibility from a certified public accountant which demonstrates that the applicant has access to sufficient funds to provide services for a minimum of six months; and

   (2) proof of professional liability insurance, acceptable to PSD.

6. F. Changes, additions or revisions: Applicant community home changes, additions or revisions to the information contained in the original application shall be submitted to PSD for approval before implementation. PSD may request, in writing and by certified mail, additional information to support the application. The requested information shall be submitted within 30 calendar days of PSD’s request. An applicant community home’s failure to respond to PSD’s request for information within 30 calendar days shall be construed as voluntary withdrawal of an application.

[8.26.6.9 NMAC - N, 02/28/2014]