MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION RESIDENTIAL TREATMENT AGENCY SUPERVISORY REVIEW
DATE	NAME OF AGENCY/SITE	ADDRESS
LICENSURE PERIOD	NAME OF PERSON(S) ATTENDING CONFERENCE
CAPACITY	GENDER	AGES	CONTRACT Yes No	ACCREDITATION BY COA JC CARF N/A
A survey of your facility has been conducted, and you are hereby notified of the standard findings as stated below.
(Items marked indicate non-compliance)
ITEM	ITEM	ITEM
Basic Core Requirements (Section 35-71.040)	Fire Drills	Lighting sufficient and safely shielded
The license is posted in a conspicuous place	Work Experience	Record Keeping (Section 35-71.090)
The License reflects accurate information	Recreation	Children’s Records
Organization and Administration (Section 35-70.040)	Living Arrangements	Infant/Toddler Care (Section 35-71.100 $ 110
Governing Body Responsible	Hygiene & Clothing	General Physical Space Requirements
Financial Management	Food & Nutrition	Diapering Space
Personnel (Section 35-71.045)	Religious Requirements	Outdoor Space/Equipment Swimming/Wading Pools
Personnel Manual	Education	Sleeping Equipment
Personnel Records	Transitional Living	Tables, Seating and Play Equipment
Staff Qualifications & Requirements (Section 35-71.050)	Health Care (Section 35-71.075)	Child Care Program
Administrative & Supervisory Personnel	Health Care Procedures
Professional Personnel	Medication: Storage and Documentation	Maternity Care (Section 35-71.120)
Direct Care Staff (Staff: Child Ratios)	Building, Grounds & Equipment (Section 35-71.080)	Health Care
Social Services Program (Section 35-71.060)	Building(s) meets zoning and building codes	Program
Intake & Admission	Buildings, Grounds and furnishings maintained, clean & safe	Specialized Standards (Section 35-71.130)
Evaluation & Planning	Sleeping Rooms – adequate space and furnished with windows	Personnel Requirements
Discharge from Care	Restroom accommodations adequate for capacity, and furnished	Staff: Child Ratios
Protection & Care of the Child (Section 35-71.070)	Combustible, poisonous, or flammable substances appropriately stored and locked	Locked Isolation
Incident Reports	Sanitation, Sewage, water and fire inspections all updated and approved	Intensive Residential Care (Section 35-71.140)
Discipline & Control	Personnel Requirements
Physical Restraint	Staff: Child Ratios
COMMENTS:
AGENCY REPRESENTATIVE	LICENSING CONSULTANT