(b) To become licensed as a VFCA health facility, the VFCA shall file an application for licensure with the department and the office in such manner and on such forms as prescribed by, or acceptable to, the department and the office. The application shall:

1. (1) contain the name of the VFCA, the kind or kinds of limited health-related services to be provided, the location and physical description of the physical plant, and such other information as the department and the office may require;

2. (2) demonstrate to the department’s satisfaction that the applicant meets the following requirements:

   1. (i) the applicant operates a residential program as defined in section 769.1 of this Part;

   2. (ii) the applicant does not:

      1. (a) appear on the NYS Office of the Medicaid Inspector General Medicaid Fraud exclusion list;
      2. (b) appear on the office fiscal sanction list;
      3. (c) have a record of poor performance on the audit and quality control list of audited contracts and list for A 133 single audit reports;
      4. (d) appear on the Internal Revenue Service charities revocation list; or
      5. (e) appear on any other applicable New York State exclusion lists, unless the applicant can provide proof that it is implementing a corrective action plan;
   3. (iii) the applicant shall describe how it will provide the core limited health-related services as set forth in section 770.1 of this Title, and, if it seeks to be licensed to provide other limited health-related services, how it will provide other limited health-related services as set forth in section 770.2 of this Title;
   4. (iv) the applicant shall demonstrate that it has arranged for adequate staffing to provide the limited health-related services that it is applying to be licensed to provide;
   5. (v) the applicant shall demonstrate that it will have an adequate physical plant environment and equipment as described in section 769.3 of this Part;
   6. (vi) the applicant shall document that it has a medical director responsible for establishing adequate and appropriate policies and procedures for the provision of health services at the VFCA health facility for which the applicant is seeking approval, including clinical supervision by the medical director and/or one or more other health care practitioners as required by section 770.1(a)(3) of this Title.

(c) The VFCA health facility shall be licensed to provide limited health-related services only to the following persons:

1. (1) children and youth in the custody of the local department of social services (LDSS) and in the care of a VFCA in accordance with sections 770.1 and 770.2 of this Title;
2. (2) children and youth in the custody of the LDSS but not in the care of a VFCA, in accordance with section 770.2 of this Title;
3. (3) children and youth who were in the custody of the LDSS for up to one year after discharge from the custody of the LDSS, in accordance with section 770.2 of this Title.